Unique Plan Description: Stroke Under Investigation
Plan Selection Display: Stroke Under Investigation
PlanType: Medical                                 
Version: 4          
Begin Effective Date: 2023-07-25 15:04:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-09-12 12:01:42
Available at all facilities: Yes

Stroke Under Investigation
Vital Signs
	Vital Signs
		T;N, Q1H, 4, Dose(s)/Time(s)
		T;N+240, Q4H
Activity
	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
Tomorrow's Lab
	Lipid Panel
		T+1;0400, Routine, spec type = Blood
	Glucose POC - RN
		T+1;0400, To be fasting
	Hemoglobin A1C
		T+1;0400, Routine, spec type = Blood
IV Solutions

Medications
	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
Patient Care
	Neurological Assessment-Focused
		T;N, Q1H, 4, Dose(s)/Time(s)
		T;N+240, Q4H-Sch
	Complete NIH Stroke Assessment
		T;N, Once
		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, Once
	Notify MD
		if temp >100.4F
		if SaO2 <94%
		if SBP >220, or DBP >120
		if AIC > 5.6 % for consult to diabetic educator
	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
	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. Stroke
	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 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 recommends Methodist Speech Therapy; call 402-354-4461 and leave message for consult
	Consult Speech Language (FH), Evaluate and Treat
		Aphasia
			Comment: stroke.
Consults/Follow-up
	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 on Dr. Jim Kult's patient 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

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

DVT VTE Prophylaxis (FH)
Laboratory
	CBC with Diff
		T;N, Routine, spec type = Blood
		T+1;0500, Routine, EVERY OTHER DAY, spec type = Blood
		T+1;0500, Routine, Q24H 3 Day(s), spec type = Blood
		T+1;0500, Routine, Q24H, spec type = Blood
	BMP
		T;N, Routine, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Routine, spec type = Diagnostic Blood
		T+1;0500, Q24H, spec type = Therapeutic Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Routine, spec type = Diagnostic Blood
Medications
		See VTE Risk Assessment for patient risk score(NOTE)*
	Lovenox
		40 mg, Syringe, SUBCUTANEOUS, DAILY
			Comment: NOTIFY physician if platelets < 130,000
		30 mg, Syringe, SUBCUTANEOUS, BID
			Comment: NOTIFY physician if platelets < 130,000
		For CrCl < 30 mL/min(NOTE)*
		30 mg, Syringe, SUBCUTANEOUS, DAILY
			Comment: NOTIFY physician if platelets < 130,000. D/C lovenox if INR > 1.8
		For Patients > 150 kg(NOTE)*
		40 mg, Syringe, SUBCUTANEOUS, BID
			Comment: NOTIFY physician if platelets < 130,000
		40 mg, Syringe, SUBCUTANEOUS, DAILY
			Comment: NOTIFY physician if platelets < 130,000
Anticoagulants
		Baseline INR required for Coumadin(NOTE)*
	warfarin
		5 mg, Tab, By Mouth, Once
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		2.5 mg, Tab, By Mouth, Once
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		10 mg, Tab, By Mouth, Once
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		5 mg, Tab, By Mouth, DAILY
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		2.5 mg, Tab, By Mouth, DAILY
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		10 mg, Tab, By Mouth, DAILY
			Comment: Notify MD and Hold Coumadin if INR > 2.5
		ORTHO ONLY(NOTE)*
	Xarelto
		10 mg, Tab, By Mouth, DAILY
	dabigatran
		150 mg, Capsule, By Mouth, BID
			Comment: Check renal function
	Eliquis
		2.5 mg, Tab, By Mouth, BID
			Comment: Hip Replacement: Duration of therapy 35 days  Knee Replacement: 12 days
	HEParin 5000 units/mL SUBCUTANEOUS
		5,000 units, Syringe, SUBCUTANEOUS, TID
		5,000 units, Syringe, SUBCUTANEOUS, BID
Patient Care

	Impulse Foot Pumps
		To be worn at all time while patient is not bearing weight
	Sequential Compression Device
		T;N, Wear, Both legs
			Comment: To be worn at all times while patient is not bearing weight
	Anti Embolism Stockings
		TED hose, knee high, Both legs
		TED hose, knee high, Left leg
		TED hose, knee high, Right leg
		TED hose, thigh high, Both legs
		TED hose, thigh high, Left leg
		TED hose, thigh high, Right leg
	Notify MD
		Contact Physician if INR < 1.8 on Day of Dismissal
Therapies
	Consult Physical Therapy, Evaluate and Treat
		
Consults/Follow-up
	Pharmacy Consult
		D/C Lovenox if INR > 1.8
		D/C Lovenox if INR > 2.0
		Contact MD and Hold Coumadin if INR > 2.5
		Contact MD and Hold Coumadin if INR > 3.0
		Contact MD and Hold Coumadin if INR > 3.5

*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