Unique Plan Description: Gen Adm Stroke/TIA
Plan Selection Display: Gen Adm Stroke/TIA
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2023-07-25 15:30:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-03-04 07:42:10
Available at all facilities: Yes

Gen Adm Stroke/TIA
Admit/Discharge/Transfer
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
	Admit to Observation Status
		T;N
	Admit to Critical Care Inpatient Status (MH)
		T;N, Anticipated LOS 2 midnight or more
	Admit to Critical Care Observation Status (MH)
		T;N
Vital Signs
	Vital Signs
		T;N, Q1H, 4, Dose(s)/Time(s)
		T;N+240, Q4H
Activity
	Activity-As Tolerated
		
	Up in Chair
		TIDWM
		T+1;0001, TIDWM
	Bedrest
		Once, 24, hr
	Elevate head of bed
		Elevate head of bed 30 degrees
			Comment: Continously
Diet
	NPO
		If fails nurse swallow screening, keep NPO until speech therapy evaluation. If no dysphagia, advance diet to General
Laboratory
	Glucose POC - RN
		Once
	Lipid Panel
		T+1;0400, Routine, spec type = Blood
	PT - MH/WH/JE
		T+1;0400, Routine, spec type = Blood
	Prothrombin Time (PT) - FH
		T+1;0400, Routine
	Glucose POC - RN
		T+1;0400, To be fasting
	Hemoglobin A1C
		T+1;0400, Routine, spec type = Blood
	TSH
		T+1;0400, Routine, spec type = Blood
Diagnostic Tests
	CT Head w/o Contrast
		T;N, Stat, CVA
	CTA Head
		Routine, CVA
	CTA Neck
		Routine, CVA
	MRI Brain w/o Contrast
		Routine, Cerebrovascular Accident/Stroke
	Echo Resting w Bubblestudy
		T+1;0400, Routine, Indication: Cerebral vascular accident
	Chest 2 View
		Routine, Stroke
	TEE Transesophageal Echocardiogram
		T+1;0001, Routine
	Carotid Artery Duplex Bil
		T+1;0001, Routine, Indication: CVA
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
Medications
	Tylenol
		650 mg, Tab, By Mouth, Q4H, PRN, 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
	Pepcid
		20 mg Injection IV PUSH BID
			Comment: convert to PO when taking PO
	pantoprazole IV
		40 mg, Injection, IV Push, DAILY
			Comment: Convert to PO when taking PO
		For patients <75 years (High-Intensity Statin) AND LDL >or = 70mg/dL(NOTE)*
	Lipitor
		40 mg Tab BY MOUTH DAILY
		80 mg Tab BY MOUTH DAILY
		For patients > or = to 75 years (Moderate-Intensity Statin) OR not a candidate for High-Intensity Statin AND LDL >or = 70mg/dL(NOTE)*
		10 mg, Tab, By Mouth, DAILY
		20 mg, Tab, By Mouth, DAILY
	labetalol  injection
		10 mg = 2 mL, Injection, IV PUSH, Q10MIN, PRN, see comment, Duration: 2 Dose(s)/Time(s)
			Comment: Systolic bp > or= to 220 or DBP > = to 120. Give over 2 minutes. Maximum of 20mg/4hrs; Notify MD if labetalol 10mg, IV q10min PRN x2 doses is not effective.
	aspirin
		81 mg, Tablet-Enteric-Coated, BY MOUTH, Once, NOW
			Comment: if NPO may switch order to aspirin 300mg rectal supp
		81 mg, Tablet-Enteric-Coated, BY MOUTH, DAILY, T+1;0900
			Comment: if NPO may switch order to aspirin 300mg rectal supp
	Plavix
		75 mg Tab BY MOUTH DAILY
			Comment: If ASA allergy
Patient Care
	Resuscitation Status
		T;N, Full Code
		T;N, No Code
	Neurological Assessment-Focused
		T;N, Q1H, 4, Dose(s)/Time(s)
		T;N+240, Q4H-Sch
	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
			Comment: on admission
	Notify MD
		if temp >100.4F
		if SaO2 <94%
		if SBP >220, or DBP >120.
	Bladder Scan
		PRN unable to void, every 4 hours 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
	Cardiac Telemetry Monitoring
		Telemetry Indications: Stroke/TIA
	Notify MD
		to request starting home blood pressure medications after 24 hours if neurologically stable
		If LDL>70 and not already on a statin
		If patient is diabetic and HGB A1C is >6.5 to obtain referral for diabetic educator to see while inpatient
	Sequential Compression Device
		T;N, Apply, Once
			Comment: contraindicated with PVD. Knee High
	Complete PHQ-9
		T;N
			Comment: Notify attending for score >5
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: Stroke
			Comment: within 24 hours of admission.
	Smoking Cessation Education
		T;N
			Comment: If active smoker within past 1 year.
	Smoking Cessation Education RT (FH)
		T;N
			Comment: If active smoker within past 1 year.
	Consult Speech Therapy (JE)
		Stroke
			Comment: evaluate within 24 hours, MBS if appropriate and order diet as recommended.
	Consult Speech Language (MH), Evaluate and Treat
		Stroke
			Comment: Evaluate within 24 hrs, MBS if appropriate. Order diet as recommended by 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 recommended. Call 402-354-4461 and leave message for consult
Consults/Follow-up
	Consult Social Work
		Discharge Planning
	Consult Diabetes Educator
		Needs Diabetic Assessment
			Comment: if A1C >5.6 (pre diabetic) or diabetic
	Pharmacy Consult - Warfarin (Coumadin) Therapy
		T;N, To dose coumadin in hospital
	Pharmacy Consult - Review Meds for ______
		
	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
	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

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

nicotine 14 mg/24 hr Patch
Medications

	nicotine
		14 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T+1;0900
Patient Care
	Medication patch site check
		T;N+720, Q12H-Sch

nicotine 21 mg/24 hr Patch
Medications
	nicotine
		21 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T+1;0900
Patient Care
	Medication patch site check
		T;N+720, Q12H-Sch

nicotine 7 mg/24 hr Patch
Medications
	nicotine
		7 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T;N+1440
Patient Care
	Medication patch site check
		T;N+720, Q12H-Sch

Peripheral Lock - Access
Medications
	sodium chloride 0.9% flush injectable soln
		10 mL Syringe IV PUSH BID
		10 mL, Syringe, IV PUSH, Q5MIN, PRN, IV line flush
	lidocaine 1% injectable solution (MH/WH/FH)
		0.1 mL, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start
	sodium chloride bacteriostatic 0.9% injectable soln
		0.1 mL, Injection, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start, use if patient has lidocaine allergy.
	Sodium Chloride 0.9% IVPB Flush
		25 mL, IVPB, Q1H, PRN, IV line flush, 5 min(s)
			Comment: Use if medication not compatible with primary line or there is no primary line;  infuse 25mL.
Patient Care
	Peripheral Lock-Insert
		T;N

VTE Prophylaxis
Medications
	Lovenox
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T;N
			Comment: (CrCl>30) Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T;N+480
			Comment: (CrCl>30) Start 8 hours after admission. Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T+1;0900
			Comment: (CrCl>30) Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
	HEParin 5000 units/mL SUBCUTANEOUS
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T;N
			Comment: VTE Prophylaxis
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T;N+480
			Comment: Start 8 hours after admission. VTE Prophylaxis
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T+1;0600
			Comment: VTE Prophylaxis
Patient Care
		Sequential Compression Device and Anti Embolism Device orders will not suppress the VTE Advisor(NOTE)*
	Sequential Compression Device
		T;N, Apply, Once
	Anti Embolism Stockings
		T;N, Apply, Once
			Comment: knee high
	VTE Prophylaxis Contraindication
		High Risk of Bleeding
		Procedure Planned
		ASA order meets prophylaxis requirement
		If patient is low risk or further evaluation needed, complete advisor:(NOTE)*
	VTE Advisor
		Medical

Insulin Sliding Scale - NovoLOG
Laboratory
	Glucose POC - RN
		T;N, QIDACHS
		T;N, 15 minutes after carbohydrate source or medication administered
	Hemoglobin A1C
		T+1;0400, Routine, spec type = Blood
	Order Lab
		T;N
			Comment: Blood Glucose (POC) as needed for signs and symptoms of hypoglycemia for patients with diabetic medication orders or known diabetic.
Medications
	Standard Dose NovoLOG
		2 - 12 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale, Routine
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 2 units,200 - 249 = 4 units,250 - 299 = 6 units,300 - 349 = 8 units,350 - 399 = 10 units.Over 399 = 12 units,<< Sliding Scale Comments >> Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6 hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).  Enter as Q6H-SCH  PRN
	Moderate Dose NovoLOG
		4 - 24 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 4 units,200 - 249 = 8 units,250 - 299 = 12 units,300 - 349 = 16 units,350 - 399 = 20 units.Over 399 = 24 units,<< Sliding Scale Comments >> Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6hours if patient is NPO or not on oral diet (tube/enteral feedings,TPN, etc). Enter as Q6H-SCH PRN
	High Dose NovoLOG
		5 - 30 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 5 units,200 - 249 = 10 units,250 - 299 = 15 units,300 - 349 = 20 units,350 - 399 = 25 units.Over 399 = 30 units, << Sliding Scale Comments >>Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).  Enter as Q6H-SCH  PRN
	glucose oral gel (JE)
		15 gm, Gel, By Mouth, Q15MIN, PRN, low blood sugar
			Comment: For blood glucose is 60-70mg/dL as an alternative to apple juice. Notify provider if given with corresponding POC glucose recheck value
	Dextrose 50%
		25 mL, Injection, IV PUSH, Q15MIN, PRN for low blood sugar, Routine
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	Dextrose 10% in Water (FH)
		250 mL, Injection, IVPB, Q30MIN, PRN for low blood sugar, infuse over 30 min(s)
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	glucagon
		1 mg, Injection, IV Push, Q15MIN, PRN for low blood sugar, T;N
			Comment: Give if blood glucose < 70mg/dL AND if dextrose 50% injectable unavailable OR inadequate response to IV dextrose 50%. May give SubQ or IM if patient does not have IV access. Notify provider if given with corresponding POC glucose recheck value.
Patient Care
	Order Lab
		T;N, RN may change schedule of point of care glucose and sliding scale insulin order to every 6 hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).. Enter POC order as Q6H-SCH, TIMED and medication order as Q6H-SCH PRN.
	Diabetic Snack
		T;N, Give snack (1 complex carb (15g), 1 protein snack (7g) ) anytime insulin is administered after the evening meal is complete and POC glucose is <150mg/dL.
	IV-Maintain
		T;N
			Comment: Patient should have IV site while on hypoglycemia protocol
	Hypoglycemia Treatment Parameters
		T;N, Hypoglycemia protocol initiated for patients with glucose <70mg/dl. Patient should have an IV while in Hypoglycemia protocol.
		T;N, glucose <60 mg/dL treat with Dextrose 50% 25 mL OR glucagon 1mg as per medication orders. Notify provider as per critical result protocol.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy
		T;N, glucose 60-70 mg/dL, administer 4 oz apple juice, 4 oz non-diet soda, or glucose gel (MJE/MFH).  If patient NPO or unable to tolerate oral intake, give Dextrose 50% 25 mL OR glucagon 1mg as per medication orders.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, After initial treatment of any glucose value </= 70 mg/dL, repeat POC glucose in 15 min; if result </= 70mg/dL continue treating as per protocol and rechecking glucose 15 min after treatment until glucose >70mg/dL.
			Comment: Notify provider of all treatments given and corresponding POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, Once glucose is within normal limits, give 1 complex carb and 1 protein source (such as ½ sandwich OR 1 individual container of peanut butter and 3 packs of crackers) or patient meal if patient able to take orals to prevent recurrent hypoglycemia.
			Comment: When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.

*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