Doctor’s orders

ISCHEMIC STROKE ORDERS
WITHOUT ALTEPLASE (TPA)
1. Admit inpatient to:  Telemetry  Meridian 6 (satellite telemetry) OR if critically ill  to ICU  to CCU
2. Attending Physician:
3. Condition:
4. Code Status:
5. Allergies/Intolerances:
6. Diet:
 NPO
 Initiate nursing bedside swallow screen if po medications ordered. Ok to give po meds with sips of water only if
 Diet per Speech Pathology swallow evaluation 7. Activity:  HOB up 30°  Bed Rest X 12 hrs then per PT  OOB with Assist until PT Evaluation  Bed Flat
8. Vital Signs:  every 4 hrs x 72hrs, then every 8 hrs
 Notify MD if:
 SBP > 200 or < 100, DBP > 100 or <50
9. Neuro assessment:
 Every 2hrs x 8hrs, then every 4hrs x 72hrs, then once daily

 Notify MD of any neurological changes
10. NIH Stroke Scale:  On admit, prn neuro status change and at discharge
11. I&O:  Every 8 hrs
12. Oxygen:
 Initiate oxygen protocol to keep SpO2 > 92%
 Notify MD if >4L O2 required to maintain sats>92%
 RT per Pulmonary Treatment Protocol
13. IVF:  Initiate IV protocol Start 0.9% NS @ ______ml/hr
14. Labs:
 UA with C&S if positive leukocytes  CBC  CMP  ESR
 PT / INR  HgA1C  CBC w/diff  Cardiac enzymes
 Fasting Lipid Panel  Type and screen (all tPA patients)  PTT  Other:_________________
*consider hyper-coag work up (see back of orders for reference)
15. Imaging/Testing:
 CT head w/o contrast Date: __________
 MRI Brain w/o contrast Date: __________  MRA angiogram head and neck Date: _______  Lower extremity venous duplex Date: __________  Trans-esophageal Echocardiogram Date: _____  Echocardiogram with bubble study Date: __________ PHYSICIAN INITIAL:
American Stroke Association MS01-01-335 03/10/10 rev. 06/07/12 ISCHEMIC STROKE ORDERS
WITHOUT ALTEPLASE (TPA)
16. Medications:
 Acetaminophen 650 mg every 4 hrs PO/PR, PRN for temp > ________ or discomfort.  Ranitidine (Zantac) 50 mg IV every 8 hrs; Change to 150 mg PO every 12hrs when tolerating PO  Pantoprazole (Protonix) 40 mg IV every day; Change to 40mg PO every day only when tolerating PO (Do NOT

administer if patient is taking Plavix)
 Analgesic: ________________________________________  Antiemetic:________________________________________  Sleep/Anxiety:________________________________________  Bowel Care: ________________________________________  Statin:__________________________ (if LDL >70 - Core Measure #6)
 Diabetic Management: See adult inpatient subcutaneous insulin orders: Please Flag for Physician
17. Antiplatelet/Antithrombotic Therapy: (to be given by end of hospital day 2 – Core Measure #5)
NOTE: DO NOT start until CT results called to MD
 Aspirin 325 mg PO today then daily -OR-  Aspirin 81mg PO today then daily -OR-
 Clopidogrel (Plavix) 75 mg PO today then daily  Aspirin/Dipyridamole (Aggrenox) 25/200 mg PO BID  Warfarin (Coumadin) ____mg PO today then daily 18. VTE Prophylaxis: (to be started the day of or the day after hospital admission - Core Measure #1)
 *CALL MD PRIOR TO INITIATION OF PHARMACOLOGIC RX
 Intermittent Pneumatic Compression (IPC)  Enoxaparin (Lovenox) 40 mg SQ every day  If contraindicated, provide reason ____________________________________________________ Pharmacy may adjust for CR CL < 30 ml/min for patients without Alteplase (TPA) and may adjust for CR CL<39 ml/min for patients with Alteplase (TPA). No pharmacologic prophylaxis for patients with hemorrhagic stroke sooner than 72 hours or earlier with neurology recommendation only. PHYSICIAN INITIAL:
American Stroke Association MS01-01-335 03/10/10 rev. 06/07/12 ISCHEMIC STROKE ORDERS
WITHOUT ALTEPLASE (TPA)
19. Therapy Consults: (Core Measure #10)
 Speech Pathology consult – Evaluate and treat, RN to complete bedside swallow screen prior to oral medications and Speech Pathology assessment  Physical therapy consult – Evaluate and treat  Occupational therapy consult – Evaluate and treat 20. Other Consults:
 Case Management for Discharge/Rehab Planning Needs  Physiatry consult - Fax order and face sheet to Physiatry consult number 1-888-797-3422 (1-888-79R-EHAB) 21. Patient and Family Education (Core Measure #8)
 Stroke Education (individualized)
Provide education to patient and/or caregiver about: 1. Activation of Emergency Medical System 4. Patient’s specific risk factors for stroke  Antithrombotic/Anticoagulant Education PHYSICIAN SIGNATURE:
American Stroke Association MS01-01-335 03/10/10 rev. 06/07/12

For Physician Reference Only
Hyper-Coag work up for consideration:
Protein S and C
Anticardiolipin Antibody
Factor V Leiden
Lupus Anticoagulant
Prothrombin Gene Mutation
Antithrombin III
Homocysteine
American Stroke Association MS01-01-335 03/10/10 rev. 06/07/12

Source: http://match-access.com/for_physicians/documents/IschemicStrokeOrderswithouttPAms01-01-3356-7-12.pdf