Unique Plan Description: Neurosurgery Subarachnoid Hemorrhage Admission Adult Plan Selection Display: Neurosurgery Subarachnoid Hemorrhage Admission Adult PlanType: Medical Version: 10 Begin Effective Date: 12/31/2100 00:00 End Effective Date: Current Available at all facilities Pre-Op Subarachnoid Hemorrhage Adult Admit/Transfer/Discharge Admit Type Assign to Utilization Review assessment protocol Admit Patient Inpt Neurosurgery, Subarachnoid Hemorrhage (DEF)* Neurosurgery Transfer Patient Condition Patient Condition Serious (DEF)* Good Fair Critical Code status other than full code requires a separate physician order.(note)* Code Status Full Code Vital Signs/Monitoring Vital Signs Neurological Checks Notify Provider Vital Signs SBP> 160, SBP< 90, HR> 100, T> 38.5, ICP> 20 for >5 min Comments: If patient has EVD Patient Monitor Monitor and record ICP Intake and Output-Strict Monitor and record EVD output, Notify Provider Bedrest Head of Bed Elevate HOB, 30-40 Degrees Nursing EVD, Passive, 20cm H2O (DEF)* EVD, Passive, 15cm H2O EVD, Passive, 10cm H2O EVD, Passive, 5cm H2O Drain/Tube Insertion Nasogastric/Orogastric Tube, Low Intermittent Suction, ONCE Nasogastric/Orogastric Tube, Low Intermittent Suction Urinary Catheter Insertion Indwelling Catheter, Bedside Drain, ONCE Urinary Catheter Maintenance Indwelling Catheter, Bedside Drain Nursing Swallow Assessment Before administering any PO medication, perform swallow assessment per nursing protocol with 30ml water. Notify Provider and record results., ONCE Patient Education Perform Stroke Education Isolation Precautions Standard Precautions (DEF)* Standard Precautions Contact Precautions
Standard Precautions Droplet Precautions Standard Precautions Contact Precautions Droplet Precautions Standard Precautions Neutropenic Precautions Standard Precautions Airborne Precautions Diet NPO Except Medications (DEF)* Including Medications May Have Ice Chips Continuous Infusions NS-KCl 20mEq/L 1000mL IVF 1000 ml, 75 ml/hr, IV, Injection Medications nimodipine oral solid 60 mg, PO, Cap, Q4HR (DEF)* 30 mg, PO, Cap, Q2HR phenytoin IV 1,000 mg, IVPB, Injection, ONCE phenytoin IV 100 mg, IVPB, Injection, Q8HR (phenytoin) famotidine IV 20 mg, IV, Injection, BID propofol 10 mg/ml in 100mL PREMIX IV Drip (mcg/kg/min) (IVS)* premix product INET parameters IV Emulsion, 5 mcg/kg/min = Titration Increment, 5 min = Titration Interval Comments: Titrate to goal RASS of.*conc: 10 mg/ml* propofol INET premix 1,000 mg/100 ml 1,000 mg, 5, mcg/kg/min hydralazine IV labetalol IV Common PRN and Routine Medications Adult Subphase(SUB)* >>> Venous Thromboembolism Prophylaxis(NOTE)* Venous Thromboembolism Risk Assessment Moderate Risk-1 Minor Risk (DEF)* Special Circumstances Apply Moderate Risk-1 Minor Risk Prophylactic Medication Contraindicated Moderate Risk-1 Minor Risk High Risk-A Major Risk or >1 Minor Risk Special Circumstances Apply High Risk-A Major Risk or >1 Minor Risk Prophylactic Medication Contraindicated High Risk-A Major Risk or >1 Minor Risk Low Risk-No Risk Factors, No VTE Prophylaxis Required Compression Device/Stocking Seq Compress - Below the Knee Grad Compress Stocking - Knee High (DEF)* Seq Compress - Below the Knee Grad Compress Stocking - Thigh High Seq Compress - Above the Knee Grad Compress Stocking - Thigh High Grad Compress Stocking - Knee High Grad Compress Stocking - Thigh High Reason Stroke VTE Mechanical Prophylaxis Not Ordered Reason Stroke VTE Pharmacological Prophylaxis Not Ordered Reason IV Thrombolytic Therapy Not Initiated Reason Antithrombotics Not Given by End Day 2 Venous Thromboembolism Prophylaxis Adult Subphase(SUB)* Laboratory On Admission(NOTE)* CBC without Diff BMP Phosphorus Inorganic Magnesium Level
Prothrombin Time Comments: Includes INR APTT Urinalysis Urine, Urgent collect, ONCE Urine Pregnancy Qualitative Urine, Urgent collect, ONCE AM Labs(NOTE)* CBC without Diff BMP Phosphorus Inorganic Magnesium Level Prothrombin Time Comments: Includes INR APTT ABG w/meas Sat Respiratory Oxygen Therapy Nasal Cannula, Keep SPO2 greater/equal 90%, Improve Oxygenation (DEF)* Nasal Cannula, 2 L/min, Keep SPO2 greater/equal 90%, Improve Oxygenation Nasal Cannula, 4 L/min, Keep SPO2 greater/equal 90%, Improve Oxygenation Nasal Cannula, Keep SPO2 greater/equal 92%, Improve Oxygenation Rehab PT/OT/ST/AUD PT Adult Eval and Treat OT Adult Eval and Treat Speech Therapy Adult Eval And Treat Radiology/Imaging All orders for Interventional Radiology are ordered on paper order form.(note)* XR Chest 1 View Frontal XR Chest 2 Views CT Head or Brain w/ + w/o Contrast CT Angiography Head w/ + w/o Contrast MRI Brain w/ + w/o Contrast MRA Head w/ + w/o Contrast US Carotid Duplex Bilateral US Carotid Duplex Left US Carotid Duplex Right US Transcranial Doppler Complete US Transcranial Doppler Limited Diagnostic Tests All diagnostic tests must be ordered on paper diagnostic order forms.(note)* Consults/Ancillary Services All medical service consults remain on paper consult form.(note)* Post-Op Subarachnoid Hemorrhage Adult Admit/Transfer/Discharge Admit Type Assign to Utilization Review assessment protocol Admit Patient Inpt Neurosurgery, Subarachnoid Hemorrhage Transfer Patient Condition Patient Condition Serious (DEF)* Good Fair Critical
Code status other than full code requires a separate physician order.(note)* Code Status Full Code Vital Signs/Monitoring Vital Signs Neurological Checks Notify Provider Vital Signs SBP< 140, HR> 100, T> 38.5, ICP> 20 for >5min Comments: If patient has EVD Patient Monitor ICP Monitor, Monitor and record ICP (DEF)* Cardiorespiratory Pulse Oximetry ICP Monitor, Monitor and record ICP Cardiorespiratory ICP Monitor, Monitor and record ICP EVD, Passive, 5cm H2O, Constant Indicator Intake and Output-Strict Monitor and record EVD output, Notify Provider Bedrest HOB Elevated Elevate HOB, 30-40 Degrees Nursing SCIP Quality Measures Nasogastric/Orogastric Tube, Low Intermittent Suction, Constant Indicator Urinary Catheter Maintenance Indwelling Catheter, Bedside Drain Reason Urinary Catheter Not Removed Isolation Precautions Standard Precautions (DEF)* Standard Precautions Contact Precautions Standard Precautions Droplet Precautions Standard Precautions Contact Precautions Droplet Precautions Standard Precautions Neutropenic Precautions Standard Precautions Airborne Precautions Nursing Swallow Assessment Before administering any PO medication, perform swallow assessment per nursing protocol with 30ml water. Notify Provider and record results., ONCE Diet NPO Except Medications (DEF)* Including Medications May Have Ice Chips Continuous Infusions NS-KCl 20mEq/L 1000mL IVF 1,000 ml, 150 ml/hr, IV, Injection Medications albumin human 5% IV (ml) 250 ml, IV, Injection, TID, PRN Other (see comment) Comments: maintain CVP 6-12 mmhg cefazolin IV 1 gm, IVPB, Injection Powder, Q8HR, x 2 dose(s) nimodipine oral solid 60 mg, PO, Cap, Q4HR (DEF)* 30 mg, PO, Cap, Q2HR phenytoin IV 100 mg, IVPB, Injection, Q8HR (phenytoin) famotidine IV 20 mg, IV, Injection, BID propofol 10 mg/ml in 100mL PREMIX IV Drip (mcg/kg/min) (IVS)* premix product INET parameters
IV Emulsion, 5 mcg/kg/min = Titration Increment, 5 min = Titration Interval Comments: Titrate to goal RASS of.*conc: 10 mg/ml* propofol INET premix 1,000 mg/100 ml 1,000 mg, 5, mcg/kg/min hydralazine IV labetalol IV phenylephrine 160 mcg/ml in NS 250 ml IV Drip (mcg/kg/min) (IVS)* NS IV Drip - INET parameters IV, 0.1 mcg/kg/min = Titration Increment, 2 min = Titration Interval Comments: Titrate to goal MAP of.*conc: 160 mcg/ml* phenylephrine ADDITIVE - INET 40 mg, 0.1, mcg/kg/min Common PRN and Routine Medications Adult Subphase(SUB)* Reason Beta-Blocker Not Prescribed at Discharge >>> Venous Thromboembolism Prophylaxis(NOTE)* Venous Thromboembolism Risk Assessment Moderate Risk-1 Minor Risk (DEF)* Special Circumstances Apply Moderate Risk-1 Minor Risk Prophylactic Medication Contraindicated Moderate Risk-1 Minor Risk High Risk-A Major Risk or >1 Minor Risk Special Circumstances Apply High Risk-A Major Risk or >1 Minor Risk Prophylactic Medication Contraindicated High Risk-A Major Risk or >1 Minor Risk Low Risk-No Risk Factors, No VTE Prophylaxis Required Compression Device/Stocking Seq Compress - Below the Knee Grad Compress Stocking - Knee High (DEF)* Seq Compress - Below the Knee Grad Compress Stocking - Thigh High Seq Compress - Above the Knee Grad Compress Stocking - Thigh High Grad Compress Stocking - Knee High Grad Compress Stocking - Thigh High Reason Stroke VTE Mechanical Prophylaxis Not Ordered Reason Stroke VTE Pharmacological Prophylaxis Not Ordered Reason IV Thrombolytic Therapy Not Initiated Reason Antithrombotics Not Given by End Day 2 Venous Thromboembolism Prophylaxis Adult Subphase(SUB)* Laboratory Urinalysis Urine, Urgent collect, ONCE Comments: On Admission CBC without Diff BMP Phosphorus Inorganic Magnesium Level Prothrombin Time Comments: Includes INR APTT ABG w/meas Sat Sterile Body Fluid Culture + Gram Cerebrospinal Fluid, Urgent collect, ONCE Comments: Tube #1 CSF Glucose Body Fluid, Urgent collect, ONCE, Nurse collect Comments: Tube # 2 CSF Protein Body Fluid, Urgent collect, ONCE, Nurse collect
Comments: Tube # 2 CSF Cell Count and Differential Cerebrospinal Fluid, Urgent collect, ONCE Comments: Tube #3 Respiratory Oxygen Therapy Nasal Cannula, Keep SPO2 greater/equal 90%, Improve Oxygenation (DEF)* Nasal Cannula, 2 L/min, Keep SPO2 greater/equal 90%, Improve Oxygenation Nasal Cannula, 4 L/min, Keep SPO2 greater/equal 90%, Improve Oxygenation Nasal Cannula, Keep SPO2 greater/equal 92%, Improve Oxygenation Ventilator Settings General/Surgical Ventilator Protocol Ventilator Mechanics QAM Radiology/Imaging All orders for Interventional Radiology are ordered on paper order form.(note)* US Transcranial Doppler Complete Diagnostic Tests All diagnostic tests must be ordered on paper diagnostic order forms.(note)* Consults/Ancillary Services All medical service consults remain on paper consult form.(note)* Other Patient Education Perform Stroke Education *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase