Unique Plan Description: Gen Adm Stroke (Post TPA)
Plan Selection Display: Gen Adm Stroke (Post TPA)
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2023-07-25 15:12:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-04-02 15:09:51
Available at all facilities: No

Gen Adm Stroke (Post TPA)
Admit/Discharge/Transfer
	Admit to Critical Care Inpatient Status (MH)
		T;N, Anticipated LOS 2 midnight or more
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
			Comment: To Critical Care
Vital Signs
	Vital Signs
		Q15 min x 2 hours, & then Q30 min x 6 hours & then Q1 hour x 16 hours, & then Q4 hours
			Comment: Maintain SPB<180 and DBP < 105; BP goal parameters SBP < 180 mmHG, DBP <105                 mmHG. Notify provider if BP outside these parameters.
	Neurological Assessment-Focused
		T;N
			Comment: Q15 min x 2 hours, then Q30 min x 6 hours & then every 1 hour x 16 hours, & then Q4 hours.
Activity
	Bedrest
		Once
			Comment: During tPA infusion and for 12 hours after tPA infusion completed.
	Elevate head of bed
		Elevate head of bed 30 degrees
			Comment: Continuously
Diet
	NPO
		For 12 hours post tPA administration
			Comment: If fails nurse swallow screening keep NPO until Speech Therapy evaluation. If no dysphasia, advance diet to general after initial 12 hours after tPA.
Laboratory
	Glucose POC - RN
		T;N+1440, To be fasting
	CMP
		T;N+1440, Timed, spec type = Blood
			Comment: 24 hours after tpa
	Lipid Panel
		T;N+1440, Timed, spec type = Blood
			Comment: 24 hours after tpa
	INR - MH/WH/JE
		T;N+1440, Timed, spec type = Blood
			Comment: 24 hours after tpa
	Prothrombin Time (PT) - FH
		T;N+1440, Timed, spec type = Diagnostic Blood
			Comment: 24 hours after tpa
		T;N+1440, Timed, spec type = Therapeutic Blood
			Comment: 24 hours after tpa
	Hemoglobin A1C
		T;N+1440, Timed, spec type = Blood
			Comment: 24 hours after tpa
	Thyroxine Total T4 (not for screening)
		T;N+1440, Timed, spec type = Blood
	TSH
		T;N+1440, Timed, spec type = Blood
			Comment: 24 hours after tpa
	PTT - MH/WH/JE
		T;N+1440, Timed, spec type = Blood
			Comment: 24 hours after tpa
	Partial Thromboplastin Time (PTT) - FH
		T;N+1440, Timed, spec type = Diagnostic Blood
			Comment: 24 hours after tpa
	CBC with Diff
		T;N+1440, Timed, spec type = Blood
			Comment: 24 hours after tpa
Diagnostic Tests
	CT Head w/o Contrast
		T+1, Routine, CVA
			Comment: 24 hours  post tPAmay be replaced by MRI brain
	Echo Resting w Bubblestudy
		T+1;0400, Routine, Indication: Cerebral vascular accident
	Carotid Artery Duplex Bil
		T+1;0600, Routine, Indication: CVA
			Comment: at least 24 hours after tPA
		T+1;0001, Routine, Indication: CVA
			Comment: Indication: Stroke, at least 24 hours after tPA
	MRI Brain w/o Contrast
		T;N, Routine, Cerebrovascular Accident/Stroke
			Comment: 24 hours after tPA
IV Solutions
	Sodium Chloride 0.9%
		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
		1,000 mL, IV, 20, ml/hr
	niCARdipine 20mg/NS 200mL
		20 mg, EVERY BAG, 5 mg/hr
		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 of SBP < 180 and DBP <105. Discontinue order after 12hr if patient does not require IV re-initiation.
	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 the Goal parameter of SBP < 180 and DBP <105. Discontinue order after 12hr if patient does not require IV re-initiation.
	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 of SBP < 180 and DBP <105. Discontinue order after 12hr if patient does not require IV re-initiation.
Medications
	Tylenol
		650 mg, Suppository, RECTALLY, Q4H, PRN, see comment
			Comment: If unable to take oral for mild pain of fever > 100.5 Convert to oral when taking PO
		650 mg, Tab, By Mouth, Q4H, PRN, see comment
			Comment: mild pain or fever > 100.5
	Pepcid
		20 mg, Injection, IV Push, BID
			Comment: convert to PO when taking PO
	labetalol  injection
		10 mg = 2 mL, Injection, IV Push, Q10MIN, PRN, see comment, Duration: 2 Dose(s)/Time(s)
			Comment: To keep systolic BP <180 and diastolic <105.  Give over 2 minutes.  Notify MD if labetalol 10mg IV q10min PRN x2 doses is not effective.
	aspirin
		81 mg, Tablet-Enteric-Coated, By Mouth, DAILY, T+1;0900
			Comment: May enter order for 300mg rectal supp if NPO. Confirm CT or MRI brain at 24 hours post tPA is negative for hemorrhage prior to initiating anticoagulants/antiplatelet/thrombolytic medications.
Patient Care
	Resuscitation Status
		Full Code
		No Code
	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.
	Bedside Swallowing Evaluation  (JE)
		T;N+1440, Order Dx: On Admission Stroke To be done 24hrs post TPA administration
	Notify MD
		if temp >100.4F,if SaO2 <94%,SBP >= 180, DBP >= 105
			Comment: BP should be maintained below 180/105 for the first 24 hours during and after tpa treatment
		If any of the following develop within the first 24 hours of receiving TPA: bleeding, severe headache, SBP >180, DBP >105, nausea/ vomiting, neuro decline, angioedema: includes swelling of mouth, lips, tongue, face or eyes, difficulty breathing.
	No Anticoagulants/antiplatelets/thrombolytics
		T;N, For 24 hours if patient received TPA
			Comment: Confirm CT or MRI brain at 24 hours post-tpa is negative for hemorrhage prior to initiating anticoagulants/antiplatelets/thrombolytics.
	Complete Nurse Swallow Screen
		T;N, (12 hours after tPA infusion completed)
	Bladder Scan
		T;N, Q4H, unable to void, If no void or is uncomfortable.
	Straight Catheter
		bladder scan >...
			Comment: 500ml.
	Incentive Spirometer
		Q1H
	Cough, Deep Breathe
		QHAWAKE
	Patient Education
		DAILY, Personal risk factors, warning signs of stroke, activation of EMS, need for follow up after discharge, medications at discharge.
		Once, Regarding stroke. Provide patient and family folder with Krames stroke materials on admission
	No Arterial Puncture
		For 24 hours
	Do Not
		Place NG, foley or invasive line, perform invasive procedure for 24 hours after IV TPA (Alteplase)
	Vital Signs/Hemodynamic Monitoring
		Maintain SBP <180 and DBP < 105 for the first 24 hours after TPA treament
	Notify MD
		Signs and symptoms of systemic bleeding
	Sequential Compression Device
		T;N, Apply, Once
			Comment: contraindicated with PVD. Knee High
	Room/Environment
		Patient to stay in Critical Care Unit for a minimum of 24 hours after IV TPA.
	Notify MD
		If LDL > 70 and not already on a statin.
		If patient is diabetic and HGB A1C is >5.6 to obtain referral for Diabetic Educator to see while inpatient
	Cardiac Telemetry Monitoring
		Telemetry Indications: Stroke/TIA
	Anti Embolism Stockings
		
	Complete PHQ-9
		T;N
			Comment: Prior to discharge, notify attending provider if score >5
	Smoking Cessation Education
		T;N
			Comment: If active smoker within the past 1 year.
	Smoking Cessation Education RT (FH)
		T;N
			Comment: For active smokers within past 1 year.
Therapies
	Consult Physical Therapy, Evaluate and Treat
		Reason to See: Stroke
			Comment:  within 24 hours of admission
	Consult Occupational Therapy, Evaluate and Treat
		Reason to See: Evaluate and Treat
			Comment:  within 24 hours of admission. Stroke
	Consult Speech Therapy (JE)
		Stroke
			Comment: Evaluate within 24 hrs, MBS if appropriate.
	Consult Speech Language (MH), Evaluate and Treat
		Stroke
			Comment: Evaluate within 24 hrs, MBS if appropriate. Order diet as recommends Methodist Speech Therapy; call 402-354-4461 and leave message for consult.
	Consult Speech Language (FH), Evaluate and Treat
		T;N
			Comment: Evaluate within 24 hrs, MBS if appropriate. Order diet as recommends
Consults/Follow-up
	Consult Social Work
		Discharge Planning
	Consult Neurologist
		Reason for Referral: Diagnosis: Stroke
	Consult Tele Neurology (JEFH)
		Reason for Referral: Diagnosis: Stroke
	Consult Intensivist
		Refer to/Consult with: MD: MPC Pulmonary Medicine Specialists
		Refer to/Consult with: MD: Nebraska Pulmonary Specialties
	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 call the Admission Coordinator of Rehab at 402-354-4408 and leave a message.
	Consult Dietitian
		Regarding: Nutrition Assessment
	Consult Diabetes Educator
		Needs Diabetic Assessment
			Comment: if A1C >5.6 (pre diabetic) or diabetic

Oxygen Protocol
Therapies
Respiratory Therapy
	Oxygen Therapy
		T;N
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID

*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