Patient Label
Admission/Condition/Diagnosis
Admission: Admitting Physician Attending Physician Assign to Inpatient Status Transfer to ___________________
Level of Care: Physician MUST document in notes the risk, severity, and skilled nursing need of the patient to justify the status below.
ICU Stroke unitDiagnosis: Ischemic Stroke tPA Given
Condition: Critical Stable Guarded
Consult neurologist (Reminder: Physician to Physician is required)Vital Signs
For ICU Patients
Vital Signs including abbreviated NIHSS for the first 24 hours. (Q15MIN for 2 hours, then Q30 min for 6 hrs, then QHR for 16 hrs) + Vital Signs & Neuro checks Q1hr and NIHSS Qshift, with neurological changes and at discharge after the first 24 hoursFor Non ICU Patients
Vital Signs including abbreviated NIHSS for the first 24 hours.(Q 15min for 2 hours, then Q 30min for 6 hours, then QHR for 16 hours)
+ Vital Signs & Neuro checks Q4hr and NIHSS Qshift, with neurological changes and at discharge after first 24 hours
Core Measure Orders To Include: Mechanical VTE Prophylaxis
Core Measure Compliance Orders ( By checking you are ordering the orders listed on page 6)MUST order Intermittent Pneumatic Compression ( IPC) or select or document
contraindication
Sequential Compression Device Knee HighNo Mechanical Prophylaxis due to:
Amputee Congestive heart failure Patient non-compliant-refused intervention/support.
Mechanical prophylaxis refused (Required)
Right AKA Burn to lower limb
Left AKA Dermatitis o Intermittent pneumatic calf-thigh compression
Right BKA Hypervolemia o Venous foot pump
Left BKA Deformity of leg
Injury to lower extremity Sensory neuropathy
Peripheral Vascular Disease Suspected deep vein thrombosis of lower extremity
Peripheral ischemia Clouded consciousness
Vascular insufficiency of limb Surgical procedure of lower extremity
Patient enrolled in clinical trial Edema of leg
Lower limb ischemia
History of occlusive disease of artery of lower extremity At risk for falls
Comfort care management Aspiration Precautions
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Acute Ischemic
Stroke with tPA
Patient Label
Core Measure Medications
A.
AntiplateletDo not give antiplatelet for 24 hours post TPA infusion and no hemorrhage on repeat imaging study
Aspirin 81 mg 325 mg Oral Daily to start in 24 hours or Aspirin 300 mg Suppository PR daily for NPO pt
Dipyridamole Aspirin [Aggrenox] 200mg-25mg SR Cap PO BID to start in 24 hours or Aspirin 300 mg Suppository PR daily for NPO pt Clopidogrel [Plavix] Tab 75mg Oral Daily to start in 24 hours or Aspirin 300 mg Suppository PR daily for NPO pt
Medication not needed/indicated (Document reason)
B.
Anticoagulant: For atrial fibrillation or atrial flutter (current or history of)Do not give anticoagulant for 24 hours post TPA infusion and no hemorrhage on repeat imaging study
Warfarin [Coumadin] mg Oral Daily to start tomorrow at 2100 Medication not needed/indicated
+ Other Anticoagulant/Antithrombotic Medications
Enoxaparin [Lovenox] and Heparin are contraindicated if patient prescribed any non-warfarin anticoagulants including the VTE
Prophylaxis dose.
Dabigatran [Pradaxa] Cap 150mg oral BID to start in 24hrs.
Dabigatran [Pradaxa] Cap 75mg oral BID, if CrCl is 15-30ml/min, to start in 24hrs. Rivaroxaban [Xarelto] Cap 20mg oral Daily, to start in 24hrs.
Rivaroxaban [Xarelto] Cap 15mg oral Daily, if CrCl is 15-30ml/min, to start in 24hrs.
Reasons for not administering antithrombotic/anticoagulant (by end of day 2)
Bleeding Platelet count below reference range
Hemorrhagic cerebral infarction Blood coagulation disorder due to liver disease Anterior cerebral circulation hemorrhagic infarction Blood coagulation disorder
Posterior cerebral circulation hemorrhagic infarction Warfarin therapy started
Renal impairment Refusal of treatment by patient
Medical contraindication Surgical contraindication
Additional reasons for Patient not receiving therapy: Pateint enrolled in clinical trials
comfort measures only
Patient admitted for elective carotid intervention procedure
PHYSICIAN MUST INITIAL ALL PAGES THAT ARE NOT SIGNED:
ORDERSET#: ST-BH08 Published: v-
4
April
15
, 2014
Approved: FEBRUARY 2014
Page 2 of 6
Acute Ischemic
Stroke with tPA
Patient Label
C.
VTE Prophylaxis (Physician should reassess daily)If GFR < 30 ml/min, reduce Enoxaparin dose to 30 mg subq daily
Do not give anticoagulant for 24 hours post TPA infusion and no hemorrhage on repeat imaging study
Enoxaparin [Lovenox] 40 mg 30mg subq daily to start in 24 hours Exclusion Criteria for VTE Prophylaxis (Check all that apply)
Anticoagulation allergy Blood coagulation disorder due to liver disease Acute spinal cord injury Heparin induced thrombocytopenia Platelet count below reference range Indwelling epidural catheter
Blood coagulation disorder Renal impairment Lumbar puncture, spinal anesthesia,
or epidural removed within the last 2 hours Hemorrhagic cerebral infarction Refusal of treatment by patient
Bleeding Patient enrolled in clinical trial Uncontrolled or severe hypertension
Anticoagulation not tolerated Comfort care management Hypersensitivity to anticoagulants D. Statin or Other Cholesterol Reducing Medications
For LDL greater than or equal to 100 and/or pt on lipid lowering agent prior to admission
Simvastatin [Zocor] Tab 20mg oral nightly 40mg oral nightly Other Cholesterol Reducing Medications
Atorvastatin [Lipitor] Tab 20mg oral nightly 40mg oral nightly 80mg oral nightly Rosuvastatin [Crestor] Tab 40mg oral nightly
Niacin Timed- Release Cap + Simvastatin [Zocor]
Niacin Timed – Release Cap 500mg oral nightly 750mg oral nightly 1000mg oral nightly + Simvastatin [Zocor] 10mg oral nightly 20mg oral nightly
Ezetimibe [Zetia] + Simvastatin [Zocor] Ezetimibe [Zetia] 10mg oral nightly
+ Simvastatin [Zocor] 10mg oral nightly 20mg oral nightly
Acute Ischemic
Stroke with tPA
Patient Label
Medications
Blood Pressure Medications (Select one only)
Initiate if SBP greater than 180 mmHg or DBP greater than 105 mmHg on 2 readings 10 minutes apart. Target SBP 160 - 180 mmHg, DBP 90 - 105 mmHg during and 24HR post TPA.
Labetalol [Normodyne] 10MG 20MG 40MG IV PRN. May repeat Q10MIN to max of 300 mg.
DO NOT give if pulse less than 60 BPM. Give over 1 min. Labetalol [Normodyne] Infusion
-Labetalol [Normodyne] Injection 10MG 20MG 40MG IV bolus. Give over 1 min.
DO NOT give if pulse less than 60 BPM. -Labetalol [Normodyne] Infusion 2MG/MIN 4MG/MIN 8MG/MIN IV (Dose range 2 – 8 mg/min) DO NOT give if pulse less 60 BPM
niCARdipine [ Cardene ] Infusion Start IV infusion at 5mg/hour. Titrate by 2.5mg/hour Q5MIN up to 15mg/hour to target BP, then decrease to 3mg/hour.
.
Stroke Work-Up Studies
Hemoglobin A1C, Routine Once
Trans-thoracic Echo order with doppler,
colorflow and bubble study Interpreting Cardiologist Ultrasound Carotid Duplex, bilateral
CT head Without contrast With contrast MRI head Without contrast With contrast MRA Brain Without contrast With contrast
IV Fluids
Start Saline Lock + Maintain Saline Lock + Saline Flush
Sodium Chloride 0.9% [Normal Saline] 50ml/hr 75 ml/hr 100ml/hr 125ml/hr Other ml/hr Sodium Chloride 0.45% [1/2 Normal Saline] 50ml/hr 75 ml/hr 100ml/hr 125ml/hr Other ml/hr
PHYSICIAN MUST INITIAL ALL PAGES THAT ARE NOT SIGNED:
ORDERSET#: ST-BH08 Published: v-
4
April
15
, 2014
Approved: FEBRUARY 2014
Page 4 of 6
Acute Ischemic
Stroke with tPA
Patient Label
Consults
Diabetic Education Consult
For Intracranial Hemorrhage after Alteplase Infusion
Administer Cryoprecipitate 5 units/pack Single unit + Type + Screen
+ Transfuse Cryoprecipitate
+ Verify patient has signed informed consent for blood and blood products Administer Platelet Pheresis 1 unit
+ Type + Screen
+ Transfuse Platelet Pheresis
+ Verify patient has signed informed consent for blood and blood products
Administer aminocaproic acid [Amicar] 5g/250ml NS IV over 1 hour followed by 5g/250ml NS IV at 50ml/hr x 5 hours or until bleeding ceases
PHYSICIAN MUST INITIAL ALL PAGES THAT ARE NOT SIGNED:
Acute Ischemic
Stroke with tPA
Patient Label
Core Measure Compliance orders for AIS with TPA
•
Medication communication: Do not give Antithrombotic, Antiplatelet, Anticoagulants or NSAIDs for 24 hours post-TPA
infusion & no hemorrhage on repeat imaging study. Refer to the Antiplatelet and Anti-coagulant medication list on the
utilities menu under patient education.
•
Notify physician if patient exhibits any of the following during or within 24 hours after Alteplase administration: acute
neurological deterioration, new headache, acute hypertension, nausea and vomiting and a 4 point or more increase in the
previous NIHSS score:
a.
Suspect intracranial hemorrhage
b.
If Alteplase is infusing – Stop immediately
c.
Notify physician immediately
d.
STAT lab: PT/Aptt, Platelet Count, fibrinogen, type and screen
e.
STAT non contrast CT of head.
•
Notify Physician if Temp > 99.4 F, Respiratory rate > 24, Systolic BP < 110 or > 180 mmHg, Diastolic BP < 60 or > 105 mmHg,
Pulse < 50 or > 110, Blood Glucose > 140
•
Nursing: Order a non contrast CT of head 24 hrs post TPA.
•
Bedrest
•
Seizure/fall risk precautions
•
Elevate HOB > 30 degrees
•
Document fall risk assessment
•
NPO until after tPA infused then continue NPO until patient passes dysphagia screen or formal swallow study. If pt fails,
order nutrition consult.
•
Notify physician if patient passes dysphagia screen for diet order
•
Maintain O2 Sat > 92%. If < 92%, start O2 at 2 liters/min via nasal cannula and notify MD
•
Smoking cessation order : Give pt advice/counseling
•
Dietary consult: For caloric and dietary orders
•
Document that the "Stroke Information & Education for You" booklet and each component of its content was discussed
with patient / family / caregiver
•
CBC with auto diff in AM
•
Fasting Lipid panel in AM
•
Comprehensive metabolic panel in AM
•
RN case mgmt / Social Svc consult: To assess/assist with patient needs and initiate discharge planning
•
Pastoral care consult: For patient spiritual assessment as needed
•
Physical therapy consult : evaluate and treat
•
Occupational therapy consult : evaluate and treat
•
Speech therapy order to evaluate and treat and Bedside swallow evaluation
(on weekends, call facility operator to connect you to speech voicemail and leave message)
PHYSICIAN’S PRINTED NAME, SIGNATURE and ID# DATE: TIME:
