Download Physician Order Set STROKE: ISCHEMIC OR TRANSIENT

Print All
Physician Order Set STROKE: ISCHEMIC OR TRANSIENT ISCHEMIC ATTACK (TIA) ­ ADMISSION ORDERS 3560
PATIENT LABEL General Location c Admit to Inpatient Stroke Unit - Monitored Bed d
e
f
g
c Place on Observation Unit - for transient ischemic attack (TIA) patients only d
e
f
g
c Admit to Intensive Care Unit - Monitored Bed (for Round Rock only, Memorial please use ICU Admission Orders along with "Stroke - Ischemic
d
e
f
g
ICU Supplemental Orders") Responsible Service/Physicians:
Diagnosis:
Vital Signs c VS - q4h d
e
f
g
Allergies:
Activity c
d
e
f
g
Nursing Orders Assessments g
b
c
d
e
f
b
c
d
e
f
g
b
c
d
e
f
g
b
c
d
e
f
g
Nurse dysphagia screen - Nurse to complete dysphagia screening tool
Evidence Cardiac monitor Evidence Assess neurologic status - q4h alternating complete NIHSS with Modified NIHSS Measure weight - on admission 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. c Elevate head of bed d
e
f
g
c Fall precautions d
e
f
g
c Aspiration precautions d
e
f
g
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 HR greater than 110 or less than 50 c
d
e
f
g
b For SBP greater than 220 or less than 90, and / or DBP greater than 120 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 Evidence d
e
f
g
Patient/Caregiver Education Consider smoking cessation counseling for current smokers Evidence b Education, stroke c
d
e
f
g
Diet b NPO - Until nursing performs dysphagia screening (swallow screening). IF abnormal, keep patient NPO and consult Speech Therapy urgently.
c
d
e
f
g
IF normal, then give 1800 Kcal ADA diet, no concentrated sweets c Diet, diabetic - 1800 Kcal, no concentrated sweets d
e
f
g
c Diet, AHA - no concentrated sweets d
e
f
g
Physician Name (Type):
rev kcc 09/13 nmt 12/27/10 Page 1 of 3 Pager Number: Physician Order Set STROKE: ISCHEMIC OR TRANSIENT ISCHEMIC ATTACK (TIA) ­ ADMISSION ORDERS PATIENT LABEL IV Fluids Evidence c NaCl 0.9% at
d
e
f
g
Medications mL/hr Aspirin
Evidence aspirin c 325 mg tablet PO or NGT daily d
e
f
g
c 81 mg tablet PO or NGT daily d
e
f
g
c 300 mg suppository PR daily d
e
f
g
Platelet Inhibitors: Combination Agents (As alternative to aspirin)
Evidence AGGRENOX (aspirin 25 mg + dipyridamole 200 mg combination) c 1 capsule PO BID d
e
f
g
Platelet Inhibitors: Thienopyridines clopidogrel (PLAVIX) c 75 mg tablet PO or NGT daily d
e
f
g
Intensive Statin Therapy atorvastatin (Lipitor) c 40 mg tablet PO or NGT daily d
e
f
g
c 80 mg tablet PO or NGT daily d
e
f
g
rosuvastatin (Crestor) c 20 mg tablet PO or NGT daily d
e
f
g
c 40 mg tablet PO or NGT daily d
e
f
g
Comfort Medications 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 Stroke patients require DVT Prophylaxis Fondaparinux is contraindicated in epidural patients; Enoxaparin (Lovenox) may be used in epidural patients only with APMS approval Spinal or epidural hematomas can occur with the associated use of LMWHs or heparinoids and spinal/epidural anesthesia Recommend dosing based on normal renal function and ideal body weight High Risk Nursing Orders c Intermittent pneumatic compression Evidence d
e
f
g
Medications - Must select one for all Ischemic CVA / TIA patients unless Contraindicated heparin Evidence c 5,000 unit SQ TID d
e
f
g
enoxaparin (LOVENOX) Evidence c 40 mg SQ daily (1st dose 12 hours post surgery) d
e
f
g
fondaparinux (ARIXTRA) Evidence c 2.5 mg SQ daily (1st dose 12 hours post surgery) for abdominal surgery only d
e
f
g
Fondaparinux is contraindicated for patient with CrCl less than 30 mL/min. Physician Name (Type):
rev kcc 09/13 nmt 12/27/10 Page 2 of 3 Pager Number: Physician Order Set STROKE: ISCHEMIC OR TRANSIENT ISCHEMIC ATTACK (TIA) ­ ADMISSION ORDERS Laboratory b Fasting lipid profile in AM (not needed if checked in last 30 days) c
d
e
f
g
c HbA1c for diabetic patients if one not completed in 3 months prior to admission d
e
f
g
c Troponin-I q6h x 3 (CK, CKMB with first set) d
e
f
g
c BMP in AM d
e
f
g
Radiology Computed Tomography - Not needed if performed within the past 6 months c CT angiography, neck, with and without contrast Evidence d
e
f
g
c CT angiography, head, with and without contrast Evidence d
e
f
g
Magnetic Resonance Studies - MRA not needed if performed within the past 6 months
g
c MRI, brain, without contrast - (Preferred imaging studies) Evidence d
e
f
c MRA, head, without contrast (Preferred imaging studies) Evidence d
e
f
g
c MRA, neck, with contrast (Preferred imaging studies) Evidence d
e
f
g
Ultrasonography - Not needed if performed within the past 6 months c Ultrasound, carotid, Doppler, bilateral for TIA EVALUATION Evidence d
e
f
g
Diagnostic Tests c 12-lead ECG Evidence d
e
f
g
Consults b Consult to neurology c
d
e
f
g
b Consult to occupational therapy c
d
e
f
g
b Consult to physical therapy c
d
e
f
g
c Consult to case management d
e
f
g
c Consult to dietitian, adult - Patients with BMI greater than or equal to 25 Kg / M2 Evidence d
e
f
g
c Consult to respiratory therapy d
e
f
g
c Consult to speech therapy - aphasia, dysphagia, dysarthria or cognitive impairment d
e
f
g
Medication Reconciliation Form Additional Orders PATIENT LABEL 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Physician Name (Type):
Physician Signature (required):______________________
rev kcc 09/13 nmt 12/27/10 Page 3 of 3 Pager Number: Date:_____________ Time:_____________ Print All