Intracerebral Hemorrhage Admission iForm

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Admission Status

Admission Status: Inpatient Bed
Attending:
Neurologist:
Level of Care: Stroke Unit w Tele Stroke Unit w/o Tele ICU
Code Status: Full Code DNR

Intracerebral Hemorrhage Quality Indicators

Quality Indicators are required and are marked in blue boxes below.
  1. Stroke education should be provided.
  2. Venous thromboembolism prophylaxis should be prescribed.
  3. Pharmacologic VTE prophylaxis may be safe by hospital day #2.
  4. SCD's should be ordered unless patient has an anatomic limitation.
  5. Rehabilitation assessment should be performed.
Special circumstances allowing opt out of the quality measurements:
Comfort measures only

Nursing Orders

Intracerebral Hemorrhage Nursing Orders
RN to Perform simple swallow study (water test only)
Disease / Medical Condition Education: Intracerebral Hemorrhage
Discharge Instructions: Intracerebral Hemorrhage
Neuro Checks
Neuro Checks q4h
Neuro Checks qshift
Neuro Checks q2h x24hrs, then q4h x24hrs, then qshift
Neuro Checks q1h x24hrs then q2h (for ICU only)
Vital Signs
Vital Signs q4h
Vital Signs qshift
Notify MD/NP/PA for ongoing SBP>180 or DBP>105
Other Nursing Orders
Insert Peripheral IV and Saline Lock
Insert Urinary Catheter to Straight Drainage
Remove Urinary Catheter (if inserted in ED)
Intake and Output Measurements
Insert NG Tube to Low Continuous Suction
O2 via nasal cannula, maintain saturation >92%
Aspiration Precautions
Seizure Precautions
Intracranial Pressure Readings (for ICU Only)

Diet Orders

1. Consistency
NPO pending simple swallow study
Regular
Dysphagia IV: Mech Soft with Thin Liquids
Dysphagia III: Mech Soft with Liquids
Dysphagia II: Puree with Liquids
Dysphagia I: Puree with No Liquids
2. Modifier
Diabetic 1800kcal
Low Fat
2g Sodium
3g Sodium
3. Other Restrictions
Kosher
Gluten Free
Lactose Free

Activity Orders

Activity
Out of Bed as Tolerated
Out of Bed with Assistance
Out of Bed to Chair with Assistance
Head of Bed
Elevate Head of Bed 30 to 45 degrees

Intracerebral Hemorrhage Medications

The following weight is used to calculate weight-based medication dosing. Please change if incorrect.
Patient's weight: kg
Antidotes
If indicated, blood products such as platelets or FFP must be ordered separately. 1 mg of protamine neutralizes ~100 units of heparin
Phytonadione [Vitamin K] 5 mg IV once STAT
Phytonadione [Vitamin K] 10 mg IV once STAT
Protamine IV once STAT
Prothrombin Complex Concentrate (PCC)
Vitamin K above must be ordered in conjunction with PCC. Contraindications to PCC include: DIC, HIT, known reactions to factors II, VII, IX, and X, heparin, protein C and S, Antithrombin III, and Human Albumin.
Prothrombin Complex Concentrate [Kcentra] 0 units IV x1 STAT
 
Type in current INR and click button to calculate PCC dose:
INR:  
Formula  = weight x 0 units/kg = 0 units of factor IX (rounded to nearest 500 units, max 0 units)
Blood Pressure Control
Metoprolol [Lopressor] 5 mg IV q4h (first dose by LIP)
Labetalol [Trandate] 20 mg IV x1 dose STAT
For Labetalol and Nicardipine drips, please indicate titration parameters.
Labetalol [Trandate] 2 mg/min IV infusion
Nicardipine 5 mg/hr IV infusion
  *** Titrate to: SBP < MAP <
Diuretic
Goal is intracranial pressure <20 mmHg & cerebral perfusion pressure >70 mmHg
Mannitol 20% 0.25 mg/kg IV q4h x24hrs
Mannitol 20% 0.5 mg/kg IV q4h x24hrs
Neuromuscular Blockade
Neuromuscular paralysis with sedation can reduce elevated ICP by preventing increases in intrathoracic and venous pressure associated with coughing, straining, suction, or "bucking" the ventilator.
Ordering is restricted to anesthesia and intensivists. Use is for ventilated patients only.
Seizures are not obvious in a patient who is paralyzed. Use EEG monitoring if any concerns for seizure.
Rocuronium [Zemuron] 0.6 mg/kg IV x1 dose
Rocuronium [Zemuron] 10 mcg/kg/min IV infusion
Cisatracurium [Nimbex] 0.2 mg/kg IV x1 dose
Cisatracurium [Nimbex] 1 mcg/kg/min IV infusion
Propofol [Diprivan] 25 mcg/kg/min IV infusion
Anticonvulsants
Selecting any of these anticonvulsants automatically orders continuous EEG monitoring.
Forphenytoin [Cerebyx] 15 mg PE/kg IV x1 dose STAT
Phenytoin [Dilantin] 10 mg/kg IV x1 dose STAT
Lorazepam [Ativan] 4 mg IV push x1 STAT, may repeat in 10min
Vasopressors & Inotropes
Titration parameter is set to MAP>60mmHg.
Norepinephrine [Levophed] 5 mcg/min IV infusion
Phenylephrine 20 mcg/min IV infusion

VTE Prophylaxis

Pharmacologic Prophylaxis
Default selection is no pharmacologic VTE prophlaxis for now.
Pharmacologic VTE prophylaxis may be safe by hospital day #2.
Enoxaparin [Lovenox] 40mg subcut daily (for GFR≥30ml/min)
Enoxaparin [Lovenox] 30mg subcut daily (for GFR<30ml/min)
Heparin 5000units subcut q12hr
None:
Already on pharmacologic prophylaxis
Mechanical Prophylaxis
SCD's should be ordered unless patient has an anatomic limitation.
Sequential Compression Device (SCD) to bilateral legs
None:
Already on mechanical prophylaxis

Common Medications [click to show]


Insulin Management [click to show]


Labs / Microbiology

Stat Labs
Acute Care Panel (ACP)
CBC with differential
Liver Function Test (LFT)
PTT
PT / INR
Fibrinogen
Cardiac Enzymes (at 0, 6, 12, 24hrs)
Serum Osmolality
Microbiology
Blood Cultures x2
Urinalysis
Urine Culture
Nasal MRSA Swab
Pregnancy
Urine Pregnancy Test
Serum Pregnancy Test (Qualitative)
AM Labs
Lipid Panel
Acute Care Panel (ACP)
CBC with differential
Liver Function Test (LFT)
PTT
PT / INR
Vitamin B12 & Folate
Ferritin & Iron Panel

Radiology

CT studies
CT Head without contrast, STAT
CT Head without contrast, in 24 hrs
CTA Head with contrast, STAT
MRI studies
MRI Brain without Contrast, Routine
MRI Brain with Contrast, Routine
MRI Brain with and without Contrast, Routine
MRV Brain without Contrast, Routine
MRA Brain without Contrast, Routine
Other Studies
Echocardiogram (TTE) -- Cardiologist to read:
Bilateral Carotid Duplex
EEG today (if seizure suspected) ]-- Neurologist to read:
EEG continuous monitoring
Video Fluroscopic Swallow Study
Chest XR
Chest XR Portable, Today
Chest XR Portable, in AM
Chest XR PA and Lateral, Today
Chest XR PA and Lateral, in AM
Indicate Reason for CXR:
EKG
EKG 12 Lead, Today
EKG 12 Lead, in AM
EKG 12 Lead, Daily in AM
Indicate Reason for EKG:

Interdisciplinary Consult

PT/OT Eval and Treat
Speech and Swallow Eval and Treat
Social Work Consult
Nutrition Consult
Diabetes Education Consult
Wound/Ostomy Care Consult
Patient Blood Management (Bloodless) Consult