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Physician Order Set 3560
PATIENT LABEL STROKE: INTRACEREBRAL HEMORRHAGE (ICH) ­ ADMISSION ORDERS General Location: c ICU - Monitored Bed (for RRH only, MH please use ICU Admission Orders along with "Intracerebral Hemorrhage - ICU Supplemental Orders") d
e
f
g
c Stroke Unit - Monitored Bed d
e
f
g
Responsible Service/Physicians:
Diagnosis:
Vital Signs
c VS - q2h x
d
e
f
g
g VS - q4h
c
d
e
f
g VS - q1h x
c
d
e
f
Allergies:
Activity c Bed rest for 24 hrs d
e
f
g
c Elevate head of bed - 30 degrees d
e
f
g
Nursing Orders Assessments b Cardiac monitor c
d
e
f
g
Assess neurologic status c q1h with NIHSS d
e
f
g
c q2h with NIHSS d
e
f
g
c q4h with NIHSS d
e
f
g
c q4h alternating NIHSS with Modified NIHSS
d
e
f
g
b For the intubated, sedated patient, complete Glasgow Coma Scale and pupil assessment at the above chosen interval in place of NIHSS c
d
e
f
g
Evidence b Bedside swallowing evaluation - Nurse to complete bedside Dysphagia Screening Tool
c
d
e
f
g
Interventions b Glucose monitoring qAC and qHS if eating, or q6h if NPO. Complete Insulin Correction Factor set linked in Medication section- Mandatory for
c
d
e
f
g
all stroke patients
Contingency - Notify Provider: b If change in level of consciousness, change in NIHSS greater than 4 points or Modified NIHSS greater than 2 points - Call a Dr. Rapid. c
d
e
f
g
b For SBP greater than 160 or less than 90 c
d
e
f
g
b For HR greater than 110 or less than 50 c
d
e
f
g
b For Temp. greater than 100.3 F. If not cultured in past 48 hrs, perform Blood Cultures x 2, Urine C&S, and CBC with differential c
d
e
f
g
b Dr. Rapid per Protocol c
d
e
f
g
Respiratory c Oxygen therapy per protocol Source d
e
f
g
c Education, smoking cessation d
e
f
g
Patient/Caregiver Education Consider smoking cessation counseling for current smokers Evidence b Education, Stroke c
d
e
f
g
Physician Name (Type):
rev dso 06/12 Pager Number:
nmt 12/27/10 Page 1 of 3 Physician Order Set PATIENT LABEL STROKE: INTRACEREBRAL HEMORRHAGE (ICH) ­ ADMISSION ORDERS Diet b NPO - until dysphagia screening. If abnormal, NPO and consult speech therapy. If normal, give 1800 Kcal ADA diet, no concentrated sweets c
d
e
f
g
c Diet, diabetic - 1800 Kcal, no concentrated sweets d
e
f
g
c Diet, AHA - no concentrated sweets
d
e
f
g
IV Fluids g NaCl 0.9% IV at:
c
d
e
f
mL/hr
Medications Reminders - Target BP less than 160/90 mmHg or mean arterial pressure (MAP) less than 110 Evidence IV BP Management recommendations, if SBP is greater than 160 or mean arterial blood pressure (MAP) is greater than 110 Antihypertensives: Calcium Channel Blockers Evidence niCARdipine c 5 mg/hr IV continuous infusion : May increase by 2.5 mg/hr q5 minutes to maximum rate of 15 mg/hr d
e
f
g
Antihypertensives: Beta-Blockers Evidence labetalol (TRANDATE IV) c 5 mg IV q15 minutes IV Push over 1-2 minutes. May increase in 5 mg increments up to 20 mg q15 minutes. d
e
f
g
labetalol (TRANDATE IV) continuous infusion c 2 mg/minute IV continuous infusion. May increase by 2 mg/min q20 minutes to maximum rate of 8 mg/minute. d
e
f
g
Hydralazine: Anti-Hypertensive hydrALAZINE (APRESOLINE IV) c 5 mg IV q30 minutes PRN for BP control : May increase in 5 mg increments, up to 20 mg q30 minutes d
e
f
g
Medications: Comfort Medications Protocol c Comfort Medications per Scott & White Protocol Source d
e
f
g
Mandatory Glucose Monitoring for all Stroke-TIA Patients with Insulin Correction Factor. Link to Adult Insulin Correction Factor Orders (REQUIRED) Link to Adult Insulin Basal and Meal Bolus Orders DEEP VENOUS THROMBOSIS PROPHYLAXIS PROTOCOL Fondaparinux is contraindicated in epidural patients; Enoxaparin (Lovenox) may be used in epidural patients only with APMS approval Stroke patients require DVT Prophylaxis Reminders - No enoxaparin (LOVENOX) or heparin until 3-4 days after cessation of bleeding Nursing Orders b Intermittent pneumatic compression Evidence c
d
e
f
g
Laboratory c Hemoglobin A1c (HbA1c) for diabetic patients if one not completed in three months prior to admission d
e
f
g
Consults b Consult to neurology c
d
e
f
g
c Consult to neurosurgery - Infratentorial hemorrhages, decrease level of consciousness, cortical/surface hemorrhages, progressive
d
e
f
g
neurological deterioration, intraventricular blood or hydrocephalus Evidence b Consult to OT c
d
e
f
g
b Consult to PT c
d
e
f
g
c Consult to speech therapy - aphasia, dysphagia, dysarthria and / or cognitive impairment d
e
f
g
Physician Name (Type):
rev dso 06/12 Pager Number:
nmt 12/27/10 Page 2 of 3 Physician Order Set STROKE: INTRACEREBRAL HEMORRHAGE (ICH) ­ ADMISSION ORDERS Medication Reconciliation Form
PATIENT LABEL Additional Orders: 1.
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Physician Name (Type):
Physician Signature (Required):____________________ rev dso 06/12 Pager Number:
nmt 12/27/10 Page 3 of 3 Date:______________Time:________________ Print All