Unique Plan Description: Gen Adm Hemorrhagic Stroke
Plan Selection Display: Gen Adm Hemorrhagic Stroke
PlanType: Medical                                 
Version: 3          
Begin Effective Date: 2015-05-12 15:03:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-04-02 15:17:55
Available at all facilities: No

Gen Adm Hemorrhagic Stroke
Admit/Discharge/Transfer
	Admit to Critical Care Inpatient Status (MH)
		T;N, Anticipated LOS 2 midnight or more
	Admit to Inpatient Status
		T;N, Special Instructions To Inpatient Status
		T;N, ICU Critical Care, Anticipated LOS 2 midnight or more
Vital Signs
	Vital Signs
		T;N, Q1H
			Comment: for 24 hours then per provider order or protocol
		Per protocol
	Weight
		T;N, DAILY
Activity
	Bedrest
		T;N, Elevate head of bed 30 degrees
	Activity-As Tolerated
		T;N
Diet
	NPO
		T;N, Until nursing swallow completed
			Comment: If fails nurse swallow screen keep NPO until speech therapy evaluation. If no dysphagia, advance to general diet.
Laboratory
	CBC with Diff
		T;N, Stat, spec type = Blood
	D-Dimer - MH/WH/JE
		T;N, Stat, spec type = Blood
	D-Dimer Level - FH
		T;N, Stat, spec type = Blood
	INR - MH/WH/JE
		T;N, Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
	PTT - MH/WH/JE
		T;N, Stat, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Stat, spec type = Diagnostic Blood
	Glucose POC - RN
		T;N, Stat
	Hemoglobin A1C
		T;N, Stat, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
	Magnesium Level
		T;N, Stat, spec type = Blood
	Phosphorus
		T;N, Stat, spec type = Blood
	TSH
		T;N, Stat, spec type = Blood
	hs Troponin I - FH
		T;N, Stat, spec type = Blood
	hs Troponin T - MH/WH/JE
		T;N, Stat, spec type = Blood
	UA (Culture if Positive)
		T;N, Routine, Routine, spec type = Urine
	Pregnancy Test Urine
		Stat, Stat, spec type = Urine
	Toxicology Screen DAU - MH/WH/JE
		T;N, Stat, Stat, spec type = Urine
	Drug Screen Urine - FH
		T;N, Stat, Stat, spec type = Urine
Tomorrow's Lab
	Lipid Panel
		T+1;0400, Routine, spec type = Blood
	CBC with Diff
		T+1;0400, Routine, spec type = Blood
	Comprehensive Metabolic Panel
		T+1;0400, Routine, spec type = Blood
	Magnesium Level
		T+1;0400, Routine, spec type = Blood
	Phosphorus
		T+1;0400, Routine, spec type = Blood
Diagnostic Tests

	CT Head w/o Contrast
		T+1;0600, Routine, CVA
	CTA Head
		T;N, Routine, CVA
	CTA Neck
		T;N, Routine, CVA
	MRI Brain w & w/o Contrast
		T;N, Routine, Cerebrovascular Accident/Stroke
	MRA Head w Contrast
		T;N, Routine, Stroke/CVA
	MRA Neck w/o Contrast
		T;N, Routine, Cerebrovascular Accident/Stroke
	Chest 2 View
		Stroke, T;N, Routine, Findings/Abnormal
	ECG
		T;N, Routine, Indication: Stroke
IV Solutions
	niCARdipine 20mg/NS 200mL
		200 mL, IV, STAT, Start: T;N, Duration: 1 Dose(s)/Time(s), Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy.  If hypotension or tachycardia occurs, discontinue the infusion and notify provider.  IV may be re-initiated after weaning within 12hours, re-initiate at the dosing rate that maintained the Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation. Goal parameter: SBP <160 mmHG
		20 mg, EVERY BAG, 5 mg/hr
	niCARdipine 25 mg/NS 250 mL
		25 mg, EVERY BAG, 5 mg/hr
		250 mL, IV, Routine, Start: T;N+240, Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy.  If hypotension or tachycardia occurs, discontinue the infusion and notify provider.  IV may be re-initiated after weaning within 12hours, re-initiate at the dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation. Goal parameter: SBP <160 mmHG
	Sodium Chloride 0.9% with KCl 20mEq
		1,000 mL, IV, 50 ml/hr
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 100 ml/hr
		1,000 mL, IV, 125 ml/hr
		1,000 mL, IV, 150 ml/hr
	nicardipine 20mg/NS 200mL premix
		20 mg, EVERY BAG, 5 mg/hr
		200 mL, IV, STAT, Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy.  If hypotension or tachycardia occurs, discontinue the infusion and notify provider.  IV may be re-initiated after weaning within 12hours, re-initiate at the dosing rate that maintained the Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation. Goal parameter: SBP <160 mmHG
Medications
	labetalol  injection
		10 mg = 2 mL, Injection, IV PUSH, Q10MIN, PRN, see comment, Duration: 2 Dose(s)/Time(s)
			Comment: To keep SBP < 160mmHg. Give over 2 minutes. Notify MD if labetalol 10mg IV Q10min x 2 doses is not effective to keep SBP <160mmHg.
	Pepcid
		20 mg Injection IV PUSH BID
			Comment: convert to PO when taking PO
		20 mg Tab BY MOUTH BID
	aluminum hydroxide/magnesium hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL oral susp
		10 mL, Suspension-Oral, By Mouth, Q12H, PRN, indigestion
	Tylenol
		650 mg, Tab, By Mouth, Q4H, PRN for see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
		650 mg, Suppository, RECTALLY, Q6H, PRN for see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, Q12H, PRN for constipation
			Comment: Mix in 6 oz juice or water
		17 gm, Packet, By Mouth, DAILY, PRN for constipation
			Comment: Mix in 6 oz juice or water
	ondansetron
		4 mg, Injection, IV Push, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
Patient Care
	Resuscitation Status
		T;N, Full Code
		T;N, No Code
	Neurological Assessment-Focused
		T;N, Q1H
			Comment: for 24 hours then per provider order or protocol
	Intake and Output
		T;N
			Comment: strict I&O
	Elevate head of bed
		T;N, Elevate head of bed 30 degrees
	Foley Catheter
		T;N, Foley, Insert
			Comment: strict I&O
	Bladder Scan
		T;N, unable to void, every 4 hours if no void, or is uncomfortable.
	Straight Catheter
		T;N, Straight, Insert, unable to void, Patient discomfort
		T;N, Straight, Insert, unable to void, to keep volume <500ml
	Cardiac Telemetry Monitoring
		T;N, Telemetry Indications: Stroke/TIA
	Notify MD
		if SBP >160mmHg
		if temp >100.4
	Cough, Deep Breathe
		Q1HAWAKE
	Incentive Spirometer
		Q1HAWAKE
	Notify MD
		T;N, if no BM in 72 hours
		T;N, if o2 sat <94%
	Aspiration Precautions
		T;N
	Complete NIH Stroke Assessment
		T;N, Q12H-Start of Shift, 4, Dose(s)/Time(s)
			Comment: Notify provider if worsening neurological assessments or NIHSS score increases by >/= 4 points.
	Complete Nurse Swallow Screen
		T;N, Now
			Comment: on admission
	Enteral Tube
		T;N, Per Nasogastric Tube (NG), Insert, X Ray
	Seizure Precautions
		T;N
	No Anticoagulants/antiplatelets/thrombolytics
		T;N
	Sequential Compression Device
		T;N, Apply, Once
			Comment: knee high
	Complete PHQ-9
		T;N
			Comment: Notify attending for score >5
	Smoking Cessation Education
		T;N
			Comment: for active smokers within past 1 year
	Smoking Cessation Education RT (FH)
		T;N
			Comment: for active smokers within past 1 year
Therapies
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
	Consult Occupational Therapy, Evaluate and Treat
		T+1;0600, Reason to See: Evaluate and Treat
			Comment: within 24 hours. Stroke
	Consult Physical Therapy, Evaluate and Treat
		T+1;0600, Reason to See: Stroke
			Comment: within 24 hours
	Consult Speech Language (MH), Evaluate and Treat
		T+1;0600, Stroke
			Comment: within 24 hours. MBS if appropriate. Order diet as recommended. Methodist Speech Therapy; call 402-354-4461 and leave a message for consult
	Consult Speech Therapy (JE)
		T+1;0600, Stroke
			Comment: Evaluate within 24 hours, MBS if appropriate and order diet as recommended.
	Consult Speech Language (FH), Evaluate and Treat
		
Consults/Follow-up
	Consult Dietitian
		Regarding: Nutrition Assessment, Dietitian Assess and Treat
	Consult Social Work
		T;N, Evaluation
	Consult Neurologist
		Reason for Referral: Stroke
	Consult Tele Neurology (JEFH)
		Reason for Referral: Diagnosis: Stroke
	Consult Neurosurgery
		Reason for Referral: hemorrhagic Stroke
	Consult Physical Medicine (Rehab)
		Reason for Referral: Stroke associated sequelae, Refer to/Consult with: Physical Medicine & Rehabilitation
			Comment: Place the patient on Dr. Jim Kult's list and notify Admissions Coordinator of Rehab at 402-354-4408 and leave a message.
	Consult Intensivist
		Reason for Referral: Stroke

*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