Stroke - Ischemic With Lytic Therapy
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PHYSICIAN'S ORDER SHEET Stroke – Ischemic with lytic therapy Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated.
Print All
patient imprint
Allergies: _______________ Admission Status
b Stand Dysphagia Protocol/Bedside swallowing c d e f g
g Admit to inpatient to Dr. ______service. c d e f c Admit to observation to Dr. _________ service. d e f g Admit Location c Admit to location __________________ d e f g
evaluation Evidence c Glucose, blood, fingerstick. _______ One Time. Other d e f g Frequency _______________ If blood glucose greater than or equal to _____, initiate glycemic control
Code Status g Resuscitation status Full Code c d e f c Resuscitation status Do Not Resuscitate / Do Not d e f g Intubate (allow natural death) c Resuscitation status Partial Code d e f g
Vital Signs
protocol. c Measure and document intake and output Total for d e f g every 8 hours Evidence b Measure weight c d e f g Contingency b Notify provider Temp > 101; HR < 60 or > 120, RR > c d e f g 30. UO < 120 mL/4hr, or decline in neurologic status. Interventions c Elevate head of bed to ___ degrees. d e f g c Urinary catheter initiation/management d e f g c Urinary straight catheterization d e f g c Nasogastric/orogastric tube insertion/management d e f g
g Vitals per unit protocol c d e f c Vital signs every_______hours and then every d e f g _____________ b Vital signs every 15 minutes for the first 2 hours and c d e f g subsequently every 30 minutes for the next 6 hours then hourly for 24 hours after infusion Respiratory c Vital signs Increase frequency of blood pressure d e f g measurements if systolic BP is >/= 180 mm Hg or c Oxygen via __________@ _____ to maintain O2 sat at d e f g 90% or greater. diastolic is >/= 105 mmHg (see antihypertensives below to maintain BP at or below these levels) c Biphasic positive airway pressure (BIPAP) d e f g Pulse oximetry c Continuous positive airway pressure (CPAP) d e f g c Continuous d e f g c Blood gas, arterial now if not done and ________. d e f g c Spot q shift and prn d e f g c Blood gas, venous now if not done and ________. d e f g Source Activity c Pulmonary Function Testing d e f g c Ambulate with assistance. d e f g c FVC/negative inspiratory force every 6 hours d e f g c Bed rest / bed rest with bedside commode with assist d e f g c Ventilator settings d e f g c Up ad lib d e f g
Nursing Orders Assessments Patients with ischemic stroke should undergo a swallowing study before taking any foods, fluids, or
Diet
g NPO / NPO except po meds with sips. c d e f c Clear liquids d e f g c Regular diet d e f g c Therapeutic diet ____________. d e f g
medication by mouth Evidence Perform the National Institutes of Health Stroke Scale to IV Fluids estimate prognosis Evidence Avoid the use of hypotonic and glucosecontaining replacement fluids b Inclusion/Exclusion checklist for thrombolytic therapy c d e f g Source c Sodium Chloride 0.9% Rate: ____________________ d e f g Evidence c NIHSS upon admission and items 1,5,6 every 30 d e f g minutes Xs6 then every 4 hours times 4 then complete g c Saline lock d e f NIHSS every 8 hours. Source Medications b Neuro checks every 15 minutes during infusion of TPA Reminders c d e f g and every 30 minutes afterwards for the next 6 hours Do not give Aspirin, warfarin or heparin within 24 hours then hourly for 24 hours Source of administering TPA c Assess neurologic status every 2 hours d e f g Avoid sublingual NIFEdipine Evidence b Assess neuro status now and every 30 minutes c d e f g Avoid the routine use of a therapeutic dose of low Source molecularweight heparin Evidence
Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
PHYSICIAN'S ORDER SHEET
patient imprint
Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. Avoid the routine use of a therapeutic dose of Antihypertensives (during and after treatment with unfractionated heparin Evidence rtPA) Evidence to support the routine use of colony Systolic 180 230 or diastolic 105 120 mm Hg stimulating factors is inconclusive Evidence c Labetolol/NORMODYNE 10 mg IV over 2 minutes d e f g Thrombolytic therapy followed by 2 mg/min infusion, increase by 2mg/min every 5 minutes for max up to 8 mg/min. until target b Inclusion/Exclusion checklist for thrombolytic therapy c d e f g Source BP Besides bleeding complications, physicians should be c Labetolol /NORMODYNE 10 mg IV over 2 minutes, may d e f g aware of potential side effect of angioedemas that may repeat every 10 to 20 minutes to a max of 300 cause partial airway obstruction. A patient with a seizure mg/day. at the time of the stroke may be eligible for rtPA as long Systolic > 230 or diastolic 121 140 mm Hg as the physician is convinced that residual impairments c Labetolol/NORMODYNE 10 mg IV over 2 minutes d e f g are secondary to stroke and not a postictal followed by 2 mg/min infusion, increase by 2mg/min phenomenon. every 5 minutes for max up to 8 mg/min. until target c rtPA/ACTIVASE 0.9 mg/kg (max dose 90 mg) with 10 d e f g BP % of the dose given as a bolus over 1 minute, the rest c Labetolol/NORMODYNE 10 mg IV over 2 minutes, may d e f g over 1 hour repeat every 10 to 20 minutes to a max of 300 mg/day. LipidRegulating Agents Evidence Reminders c nicardipine /CARDENE infusion 5 mg/h, titrate up to d e f g desiredeffect by increasing 2.5 mg/h every 5 minutes Patients with cerebrovascular disease in the presence to a maximum of 15 mg/h of coronary heart disease or symptomatic If blood pressure not controlled consider Nipride. atherosclerotic disease should be treated with a 3 Analgesics hydroxy3methylglutaryl coenzyme A reductase Mild Pain (13) Evidence inhibitor to reduce lowdensity lipoprotein cholesterol levels to less than 100 mg/dL (less than 70 mg/dL for c acetaminophen /TYLENOL ____650 mg ____650 mg d e f g veryhighrisk patients); secondary goals of therapy orally or rectally _____every 4 hours ____every 6 include normalizing triglycerides and reducing non– hours as needed for pain highdensity lipoprotein cholesterol levels to less than c ibuprofen /MOTRIN 400 milligram orally every 4 d e f g hours as needed for pain 130 mg/dL Evidence (Contraindicated in pregnant women and children < 6 HMGCoA Reductase Inhibitors mos. of age) c atorvastatin /LIPITOR 10 milligram orally once a d e f g Moderate Pain (46) day in the evening c hydrocodone/APAP/LORTAB d e f g c atorvastatin /LIPITOR 20 milligram orally once a d e f g ____5/500_____7.5/500 ______10/500 tablet orally day in the evening every ____4 hr._____6 hr. as needed for pain c atorvastatin /LIPITOR 40 milligram orally once a d e f g c oxycodoneAPAP/PERCOCET d e f g day in the evening ____5/325______7.5/325_____10/325 tablet orally c simvastatin /ZOCOR 20 milligram orally once a day, d e f g every _____4hr._____6hr. as needed for pain in the evening oxycodone _____mg tablet orally every c d e f g c simvastatin /ZOCOR 40 milligram orally once a day, d e f g _____4hr._____6hr. as needed for pain in the evening Severe Pain (710) Evidence Anithypertensives (prior to rtPA) Consider the use of an opioid analgesic; morphine at If blood pressure does not decline and remains > a dose of 0.1 mg/kg body weight has limited 185/110 mm Hg, do not administer rtPA. effectiveness Evidence c labetalol /NORMODYNE ___ mg IV over 2 minutes d e f g c HYDROmorphone /DILAUDID 1 milligram SC/IV d e f g (may repeat times 1) every __ 4 hrs. __ 6 hours as needed for pain c Nicardipine /CARDENE 5 mg/h, titrate up by 2.5 mg/hr d e f g c morphine ____ milligram intravenously every d e f g at 5 to 15 min. intervals to a max of 15 mg/hr. When ____hours as needed for pain desired pressure is attained, reduce to 3 mg/hr. morphine ____mg intravenously every 5 minutes to c d e f g c nitroglycerin topical 2% ointment/NITROBID 2 inches d e f g a maximum of 10 mg/hr. to skin now.
Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
PHYSICIAN'S ORDER SHEET
patient imprint
Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. Antidotes and Rescue Agents Laboratory c naloxone /NARCAN ___ (0.42) milligram d e f g b Complete blood cell count with automated white blood c d e f g intravenously every ____min. (23) as needed for cell differential Evidence opiate reversal to improve mentation and RR > 10 b Complete blood cell count with automated white blood c d e f g and notify physician STAT cell differential and repeat in a.m. Evidence Antipyretics b Erythrocyte sedimentation rate (ESR) c d e f g c acetaminophen /TYLENOL 650 milligram orally or d e f g b Partial thromboplastin time (PTT), activated c d e f g rectally every 4 hours as needed for fever >100.4 b Partial thromboplastin time (PTT), activated and repeat in c d e f g c acetaminophen /TYLENOL 650 milligram orally or d e f g a.m. rectally every 6 hours as needed for fever greater b Prothrombin time (PT) and international normalized ratio c d e f g than 100.4 (INR) Evidence Laxatives b Prothrombin time (PT) and international normalized ratio c d e f g c magnesium hydroxide /MILK OF MAGNESIA 30 d e f g (INR) and repeat in a.m. Evidence milliliter orally once a day as needed for constipation c Basic metabolic panel d e f g docusate sodium /COLACE 100 milligram orally 2 c d e f g c Comprehensive metabolic panel d e f g times a day b Lipid panel c d e f g bisacodyl /DULCOLAX 5 milligram orally once a day as c d e f g c Magnesium (Mg) level, serum Evidence d e f g needed for constipation c Phosphorus level, serum Evidence d e f g c bisacodyl /DULCOLAX 10 milligram suppository d e f g c Creatine kinase, total (CKtotal) , CKMB isoenzyme, d e f g rectally once a day as needed for constipation troponin DVT Prophylaxis c Rapid plasma reagin (RPR), qualitative d e f g Mechanical methods of prophylaxis should be used b Urinalysis (UA) with microscopy c d e f g primarily in patients who are at high risk of bleeding or as an adjunct to anticoagulantbased prophylaxis. c Toxicology drug screen, urine d e f g Consider renal impairment when deciding on doses of c Hypercoagulopathy panel (protein C deficiency, protein S d e f g LMWH, the direct thrombin inhibitors, and other deficiency, lupus anticoagulant, anticardolipin antibodies, antithrombotic drugs that are cleared by the kidneys, activated protein C resistance, factor V Leiden, particularly in elderly patients and those who are at high Prothrombin gene analysis) risk for bleeding. Avoid the routine ordering of tests to identify coagulation In acutely ill medical patients who have been admitted defects (eg, protein C deficiency, protein S deficiency, to the hospital with CHF or severe respiratory disease, lupus anticoagulant, anticardiolipin antibodies, activated or who are confined to bed and have one or more protein C resistance/factor V Leiden mutation) Evidence adtioanla risk factors, inclujding active CA, previous Diagnostic Tests VTE, sepsis, acute neurologic disease, or inflammatory b 12lead ECG Evidence c d e f g bowel disease, prophylaxis with LDUH or LMWH is c Echocardiogram, transthoracic Evidence d e f g recommended. In meidcal patients with risk factors for c Electroencephalogram (EEG) Evidence d e f g VTE in whom there is a contraindication to anticoagulant c Radiograph, chest, 1 view Evidence d e f g prophylaxis, GCS or IPC is recommended. c Radiograph, chest, 2 views Evidence d e f g c Early and persistant mobilization d e f g c Radiograph, swallowing function, with cineradiography d e f g c Graded compression stockings (1530 mm Hg of d e f g and/or videoradiography (modified barium swallow) pressure at the ankle) Evidence c Sequential Compression Device d e f g CT, head or brain, without contrast on admission c d e f g c CBC every other day starting on day 4 of heparin d e f g Evidence therapy thru day 14 or until Unfractionated c CT, head or brain, without contrast on admission and in d e f g heparin/LMWH is discontinued. 24 hours of thrombolytic therapy Evidence LowDose Unfractionated Heparin c CT Angiography of the head Evidence d e f g c heparin 5,000 unit subcutaneously every 8 hours d e f g c CT Angiography of the neck Evidence d e f g LowMolecularWeight Heparins c MRA intracranial with contrast Evidence d e f g c enoxaparin /LOVENOX 40 milligram subcutaneously g d e f g c MRA extracranial with contrast Evidence d e f once a day c MRI, brain, with and without contrast Evidence d e f g Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
PHYSICIAN'S ORDER SHEET Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. c MRI, brain, with contrast Evidence d e f g c MRI, brain, without contrast Evidence d e f g c Ultrasound, carotid, Doppler, bilateral Evidence d e f g Consults c Consult to interventional neuroradiology. d e f g c Consult to neurosurgery d e f g c Consult to cardiology Evidence d e f g c Consult to dietitian, adult Evidence d e f g c Consult to internal medicine d e f g c Consult to Acute inpatient rehabilitation Evidence d e f g
patient imprint
g Consult to neurology c d e f c Consult to occupational therapy d e f g c Consult to palliative care d e f g c Consult to physical therapy d e f g c Consult to speech therapy d e f g c Consult to vascular surgery Evidence d e f g
Other: ________________________________
Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
Print Only Selected Items
Print All
PHYSICIAN'S ORDER SHEET Stroke – Ischemic with lytic therapy Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated.
Print All
patient imprint
Allergies: _______________ Admission Status
b Stand Dysphagia Protocol/Bedside swallowing c d e f g
g Admit to inpatient to Dr. ______service. c d e f c Admit to observation to Dr. _________ service. d e f g Admit Location c Admit to location __________________ d e f g
evaluation Evidence c Glucose, blood, fingerstick. _______ One Time. Other d e f g Frequency _______________ If blood glucose greater than or equal to _____, initiate glycemic control
Code Status g Resuscitation status Full Code c d e f c Resuscitation status Do Not Resuscitate / Do Not d e f g Intubate (allow natural death) c Resuscitation status Partial Code d e f g
Vital Signs
protocol. c Measure and document intake and output Total for d e f g every 8 hours Evidence b Measure weight c d e f g Contingency b Notify provider Temp > 101; HR < 60 or > 120, RR > c d e f g 30. UO < 120 mL/4hr, or decline in neurologic status. Interventions c Elevate head of bed to ___ degrees. d e f g c Urinary catheter initiation/management d e f g c Urinary straight catheterization d e f g c Nasogastric/orogastric tube insertion/management d e f g
g Vitals per unit protocol c d e f c Vital signs every_______hours and then every d e f g _____________ b Vital signs every 15 minutes for the first 2 hours and c d e f g subsequently every 30 minutes for the next 6 hours then hourly for 24 hours after infusion Respiratory c Vital signs Increase frequency of blood pressure d e f g measurements if systolic BP is >/= 180 mm Hg or c Oxygen via __________@ _____ to maintain O2 sat at d e f g 90% or greater. diastolic is >/= 105 mmHg (see antihypertensives below to maintain BP at or below these levels) c Biphasic positive airway pressure (BIPAP) d e f g Pulse oximetry c Continuous positive airway pressure (CPAP) d e f g c Continuous d e f g c Blood gas, arterial now if not done and ________. d e f g c Spot q shift and prn d e f g c Blood gas, venous now if not done and ________. d e f g Source Activity c Pulmonary Function Testing d e f g c Ambulate with assistance. d e f g c FVC/negative inspiratory force every 6 hours d e f g c Bed rest / bed rest with bedside commode with assist d e f g c Ventilator settings d e f g c Up ad lib d e f g
Nursing Orders Assessments Patients with ischemic stroke should undergo a swallowing study before taking any foods, fluids, or
Diet
g NPO / NPO except po meds with sips. c d e f c Clear liquids d e f g c Regular diet d e f g c Therapeutic diet ____________. d e f g
medication by mouth Evidence Perform the National Institutes of Health Stroke Scale to IV Fluids estimate prognosis Evidence Avoid the use of hypotonic and glucosecontaining replacement fluids b Inclusion/Exclusion checklist for thrombolytic therapy c d e f g Source c Sodium Chloride 0.9% Rate: ____________________ d e f g Evidence c NIHSS upon admission and items 1,5,6 every 30 d e f g minutes Xs6 then every 4 hours times 4 then complete g c Saline lock d e f NIHSS every 8 hours. Source Medications b Neuro checks every 15 minutes during infusion of TPA Reminders c d e f g and every 30 minutes afterwards for the next 6 hours Do not give Aspirin, warfarin or heparin within 24 hours then hourly for 24 hours Source of administering TPA c Assess neurologic status every 2 hours d e f g Avoid sublingual NIFEdipine Evidence b Assess neuro status now and every 30 minutes c d e f g Avoid the routine use of a therapeutic dose of low Source molecularweight heparin Evidence
Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
PHYSICIAN'S ORDER SHEET
patient imprint
Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. Avoid the routine use of a therapeutic dose of Antihypertensives (during and after treatment with unfractionated heparin Evidence rtPA) Evidence to support the routine use of colony Systolic 180 230 or diastolic 105 120 mm Hg stimulating factors is inconclusive Evidence c Labetolol/NORMODYNE 10 mg IV over 2 minutes d e f g Thrombolytic therapy followed by 2 mg/min infusion, increase by 2mg/min every 5 minutes for max up to 8 mg/min. until target b Inclusion/Exclusion checklist for thrombolytic therapy c d e f g Source BP Besides bleeding complications, physicians should be c Labetolol /NORMODYNE 10 mg IV over 2 minutes, may d e f g aware of potential side effect of angioedemas that may repeat every 10 to 20 minutes to a max of 300 cause partial airway obstruction. A patient with a seizure mg/day. at the time of the stroke may be eligible for rtPA as long Systolic > 230 or diastolic 121 140 mm Hg as the physician is convinced that residual impairments c Labetolol/NORMODYNE 10 mg IV over 2 minutes d e f g are secondary to stroke and not a postictal followed by 2 mg/min infusion, increase by 2mg/min phenomenon. every 5 minutes for max up to 8 mg/min. until target c rtPA/ACTIVASE 0.9 mg/kg (max dose 90 mg) with 10 d e f g BP % of the dose given as a bolus over 1 minute, the rest c Labetolol/NORMODYNE 10 mg IV over 2 minutes, may d e f g over 1 hour repeat every 10 to 20 minutes to a max of 300 mg/day. LipidRegulating Agents Evidence Reminders c nicardipine /CARDENE infusion 5 mg/h, titrate up to d e f g desiredeffect by increasing 2.5 mg/h every 5 minutes Patients with cerebrovascular disease in the presence to a maximum of 15 mg/h of coronary heart disease or symptomatic If blood pressure not controlled consider Nipride. atherosclerotic disease should be treated with a 3 Analgesics hydroxy3methylglutaryl coenzyme A reductase Mild Pain (13) Evidence inhibitor to reduce lowdensity lipoprotein cholesterol levels to less than 100 mg/dL (less than 70 mg/dL for c acetaminophen /TYLENOL ____650 mg ____650 mg d e f g veryhighrisk patients); secondary goals of therapy orally or rectally _____every 4 hours ____every 6 include normalizing triglycerides and reducing non– hours as needed for pain highdensity lipoprotein cholesterol levels to less than c ibuprofen /MOTRIN 400 milligram orally every 4 d e f g hours as needed for pain 130 mg/dL Evidence (Contraindicated in pregnant women and children < 6 HMGCoA Reductase Inhibitors mos. of age) c atorvastatin /LIPITOR 10 milligram orally once a d e f g Moderate Pain (46) day in the evening c hydrocodone/APAP/LORTAB d e f g c atorvastatin /LIPITOR 20 milligram orally once a d e f g ____5/500_____7.5/500 ______10/500 tablet orally day in the evening every ____4 hr._____6 hr. as needed for pain c atorvastatin /LIPITOR 40 milligram orally once a d e f g c oxycodoneAPAP/PERCOCET d e f g day in the evening ____5/325______7.5/325_____10/325 tablet orally c simvastatin /ZOCOR 20 milligram orally once a day, d e f g every _____4hr._____6hr. as needed for pain in the evening oxycodone _____mg tablet orally every c d e f g c simvastatin /ZOCOR 40 milligram orally once a day, d e f g _____4hr._____6hr. as needed for pain in the evening Severe Pain (710) Evidence Anithypertensives (prior to rtPA) Consider the use of an opioid analgesic; morphine at If blood pressure does not decline and remains > a dose of 0.1 mg/kg body weight has limited 185/110 mm Hg, do not administer rtPA. effectiveness Evidence c labetalol /NORMODYNE ___ mg IV over 2 minutes d e f g c HYDROmorphone /DILAUDID 1 milligram SC/IV d e f g (may repeat times 1) every __ 4 hrs. __ 6 hours as needed for pain c Nicardipine /CARDENE 5 mg/h, titrate up by 2.5 mg/hr d e f g c morphine ____ milligram intravenously every d e f g at 5 to 15 min. intervals to a max of 15 mg/hr. When ____hours as needed for pain desired pressure is attained, reduce to 3 mg/hr. morphine ____mg intravenously every 5 minutes to c d e f g c nitroglycerin topical 2% ointment/NITROBID 2 inches d e f g a maximum of 10 mg/hr. to skin now.
Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
PHYSICIAN'S ORDER SHEET
patient imprint
Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. Antidotes and Rescue Agents Laboratory c naloxone /NARCAN ___ (0.42) milligram d e f g b Complete blood cell count with automated white blood c d e f g intravenously every ____min. (23) as needed for cell differential Evidence opiate reversal to improve mentation and RR > 10 b Complete blood cell count with automated white blood c d e f g and notify physician STAT cell differential and repeat in a.m. Evidence Antipyretics b Erythrocyte sedimentation rate (ESR) c d e f g c acetaminophen /TYLENOL 650 milligram orally or d e f g b Partial thromboplastin time (PTT), activated c d e f g rectally every 4 hours as needed for fever >100.4 b Partial thromboplastin time (PTT), activated and repeat in c d e f g c acetaminophen /TYLENOL 650 milligram orally or d e f g a.m. rectally every 6 hours as needed for fever greater b Prothrombin time (PT) and international normalized ratio c d e f g than 100.4 (INR) Evidence Laxatives b Prothrombin time (PT) and international normalized ratio c d e f g c magnesium hydroxide /MILK OF MAGNESIA 30 d e f g (INR) and repeat in a.m. Evidence milliliter orally once a day as needed for constipation c Basic metabolic panel d e f g docusate sodium /COLACE 100 milligram orally 2 c d e f g c Comprehensive metabolic panel d e f g times a day b Lipid panel c d e f g bisacodyl /DULCOLAX 5 milligram orally once a day as c d e f g c Magnesium (Mg) level, serum Evidence d e f g needed for constipation c Phosphorus level, serum Evidence d e f g c bisacodyl /DULCOLAX 10 milligram suppository d e f g c Creatine kinase, total (CKtotal) , CKMB isoenzyme, d e f g rectally once a day as needed for constipation troponin DVT Prophylaxis c Rapid plasma reagin (RPR), qualitative d e f g Mechanical methods of prophylaxis should be used b Urinalysis (UA) with microscopy c d e f g primarily in patients who are at high risk of bleeding or as an adjunct to anticoagulantbased prophylaxis. c Toxicology drug screen, urine d e f g Consider renal impairment when deciding on doses of c Hypercoagulopathy panel (protein C deficiency, protein S d e f g LMWH, the direct thrombin inhibitors, and other deficiency, lupus anticoagulant, anticardolipin antibodies, antithrombotic drugs that are cleared by the kidneys, activated protein C resistance, factor V Leiden, particularly in elderly patients and those who are at high Prothrombin gene analysis) risk for bleeding. Avoid the routine ordering of tests to identify coagulation In acutely ill medical patients who have been admitted defects (eg, protein C deficiency, protein S deficiency, to the hospital with CHF or severe respiratory disease, lupus anticoagulant, anticardiolipin antibodies, activated or who are confined to bed and have one or more protein C resistance/factor V Leiden mutation) Evidence adtioanla risk factors, inclujding active CA, previous Diagnostic Tests VTE, sepsis, acute neurologic disease, or inflammatory b 12lead ECG Evidence c d e f g bowel disease, prophylaxis with LDUH or LMWH is c Echocardiogram, transthoracic Evidence d e f g recommended. In meidcal patients with risk factors for c Electroencephalogram (EEG) Evidence d e f g VTE in whom there is a contraindication to anticoagulant c Radiograph, chest, 1 view Evidence d e f g prophylaxis, GCS or IPC is recommended. c Radiograph, chest, 2 views Evidence d e f g c Early and persistant mobilization d e f g c Radiograph, swallowing function, with cineradiography d e f g c Graded compression stockings (1530 mm Hg of d e f g and/or videoradiography (modified barium swallow) pressure at the ankle) Evidence c Sequential Compression Device d e f g CT, head or brain, without contrast on admission c d e f g c CBC every other day starting on day 4 of heparin d e f g Evidence therapy thru day 14 or until Unfractionated c CT, head or brain, without contrast on admission and in d e f g heparin/LMWH is discontinued. 24 hours of thrombolytic therapy Evidence LowDose Unfractionated Heparin c CT Angiography of the head Evidence d e f g c heparin 5,000 unit subcutaneously every 8 hours d e f g c CT Angiography of the neck Evidence d e f g LowMolecularWeight Heparins c MRA intracranial with contrast Evidence d e f g c enoxaparin /LOVENOX 40 milligram subcutaneously g d e f g c MRA extracranial with contrast Evidence d e f once a day c MRI, brain, with and without contrast Evidence d e f g Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
PHYSICIAN'S ORDER SHEET Another brand of a generically equivalent product identical in dosage form and content of active ingredient may be administered unless indicated. c MRI, brain, with contrast Evidence d e f g c MRI, brain, without contrast Evidence d e f g c Ultrasound, carotid, Doppler, bilateral Evidence d e f g Consults c Consult to interventional neuroradiology. d e f g c Consult to neurosurgery d e f g c Consult to cardiology Evidence d e f g c Consult to dietitian, adult Evidence d e f g c Consult to internal medicine d e f g c Consult to Acute inpatient rehabilitation Evidence d e f g
patient imprint
g Consult to neurology c d e f c Consult to occupational therapy d e f g c Consult to palliative care d e f g c Consult to physical therapy d e f g c Consult to speech therapy d e f g c Consult to vascular surgery Evidence d e f g
Other: ________________________________
Order Initiated By: _________________________ Date/Time: _______________ Physician Signature: ________________________ Date/Time: _______________ Telephone/Verbal Orders: g c Read Back g d e f c Confirmed d e f
Released: April 2, 2009 Page &p of &P
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