PLACE LABEL HERE

STROKE: INTRACEREBRAL HEMORRHAGE (ICH)

ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

GCS Score / Point Value
(circle)
Glasgow Coma Scale (GCS) / 3-4
5-12
13-15 / 2
1
0
Eye Opening / Verbal Response / Motor Response
(4) Spontaneously / (5) Oriented / (6) Obeys Commands
(3) To speech/sound / (4) Confused / (5) Localizes
(2) To pain / (3) Inappropriate / (4) Withdraws
(1) None / (2) Incromprehensible / (3) Flexion
(1) None / (2) Extension
 / (1) None
Age / ≥ 80
< 80 / 1
0
ICH volume / ≥ 30 ml
< 30 ml / 1
0
Intraventricular Hemorrhage / Yes
No / 1
0
Infratentorial Origin of ICH / Yes
No / 1
0
ICH Score

1.Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?

Yes, admit as inpatient, proceed to # 2No, place in observation

2.If admitted as inpatient, Inpatient Physician Certification:______

Diagnosis: ______

Level of Care:Critical Intermediate Location/Specialty Unit:GMC-L Neuroscience or ICU

3.Isolation:  Contact  Droplet  Airborne For: ______

4. Consults: Neurosurgeon:______

Intensivist: ______

Neurologist: ______

Hospitalist:______

Other Consult(s):______

5. Respiratory:Initiate Oxygen for Adults Initiation and Weaning Protocol (form #34431)

6. Mechanical Ventilation Initiation Orders(form# 18389)

7.Smoking Cessation Counseling

8.OSA screen: If patient screens positive for suspected sleep apnea orhas reported sleep apnea, initiate Sleep Apnea

Orders (form #21266)

9.Diagnostics:Repeat CT head without contrastfor ICH Time:______

CTAHead with & without contrastIndication:______

orMRA Head without contrast Indication:______

MRIHead without contrast Indication:______

Other: ______

10.Use Stroke Plan of Care (form # 15694)

11.Assessment: Vital signs/neuro sign checks per level of care.

NIHSS on admission. (Call Stroke Unit for assessment)

 Hold for induced sedation/ventilator support.

Continue focused neuro assessment of presenting symptoms.

Copy to pharmacy Order writer’s initials ______

*3-3283* FORM 3-3283 REV.03/2017 Page 1 of 2

PLACE LABEL HERE

STROKE: INTRACEREBRAL HEMORRHAGE (ICH)

ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

12.  NGT to low intermittent

13. Diet:NPO until bedside swallow screen per RN

If swallow screen normal, begin diet as tolerated: ______

If swallow screen abnormal, maintain NPO, elevate head of bed 30 degrees, consult speech pathology

14. Nutrition Supplement Orders (form #31417), initiate if patient meets criteria

15. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)

16. Activity: Per Critical Care Early Mobility Standing orders

17. Rehab: Physical Therapy Occupational Therapy Speech Pathology

SCHEDULED MEDICATIONS:

18. If reversal of anticoagulation is not done in ED, physician should refer to Anticoagulant & Antiplatelet Reversal/

Rescue Guidelines, policy 500-56, attachment C and write orders.

19. Stop all antiplatelets/anticoagulantsdrugs including, but not limited to: Aspirin, Plavix (clopidogrel), Effient (prasugrel), Brilinta (ticagrelor), Aggrenox (dipyridamole and aspirin) and anticoagulants: Heparin, Lovenox (enoxaparin), Arixtra(fondaparinux),Coumadin (warfarin), Pradaxa (dabigatran)Xarelto (rivaroxaban), Eliquis (apixaban), and NSAIDs

20. IVF: ______at______ml/hr IV

21. Blood Pressure (BP) Administration Parameters (must be completed):

 Maintain BP ≤ 140 systolic if presenting BP < 220 systolic

or Maintain systolic BP < _____ mmHg

Blood pressure management(Physician to indicate which medication to use first. If not effective, call physician):

Trandate (labetalol) 10-20 mg IV ____hr PRN HTN (see below), Hold for heart rate < 50/min. Recheck BP within 30 min and notify physician if not in parameters.

or Hydralazine 10 mg IV q _____ hrs PRN HTN (see below), Recheck BP within 30 min and notify physician if not in parameters.

or  ICU only, Cardene (nicardipine): Initial infusion 5 mg/hr, increase by 2.5 mg q 15 min to max of

15 mg/hr, see Titration Protocol (form # 33883)

22. Stress ulcer prophylaxis: Pepcid (famotidine) 20 mg bid  po  IV

23. Stool softener:Colace (docusate) 100 mg po twice daily

24. Nicotine patch 14 mg apply one patch topically daily

PRN MEDICATIONS: See policy 520-06 for range orders and pain intensity guidelines.

25.If patient receiving insulin, initiate Hypoglycemia Treatment Standing Order (form # 2513)

26.If Critical or Intermediate level of care, initiate Critical Care Insulin SQ Standing Orders (form # 21386)

27.Mild pain/temp99.5F/HA: Tylenol (acetaminophen) 650 mg po or per rectum q 4 hrs prn

28.Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn

29.Constipation: Milk of Magnesia (MOM) 30 ml po daily prn

ADDITIONAL ORDERS:

______

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-3283 REV. 03/2017 Page 2 of 2