INTRACEREBRAL HEMORRHAGE (ICH) ADMITTING ORDERS INTRACEREBRAL HEMORRHAGE (ICH) ADMITTING ORDERS CODE STATUS DIAGNOSIS ATTENDING MD: ___________________________ NEUROLOGIST: ___________________________ CARDIOLOGIST: ___________________________ ALLERGIES WEIGHT ____________ kg NIHSS Score:_____________________________ Glasgow Coma Scale:________________________________ TREATMENTS
Vital signs & neuro checks every hour every 2 hours every 4 hours Other:_________ Full NIHSS Score on admission, once a shift, prn if change in neuro status 0.9% Normal Saline at ______ ml/hr Saline Lock Other:________________________________________________________________________
Bedrest, Head of bed elevated to 30°
Bathroom privileges with assistance only
O2 via nasal cannula to saturation above 96%
Dysphagia screening completed by RN prior to any oral intake or medications given Strict I&O
NGT tube to intermittent low wall suction if patient shows signs of vomiting Seizure precaution Notify Physician if: Neurological change Temperature is above 100.4° O2 saturation is less than 96%
Blood sugar is above 150 mg/Hg, if not on sliding scale Heart rate is above 120, or any other arrhythmia SBP is above 140 mmHg SBP is less than 90 mmHg CPP is less than 70 mmHg (MAP – ICP = CPP) ICP is greater than _______
NPO, including oral meds until dysphagia screen or speech therapy evaluation completed NPO except meds, until speech therapy evaluation completed
Then Start:
Regular diet Low fat, low cholesterol, 2 gram sodium INTRACEREBRAL HEMORRHAGE (ICH) ADMITTING ORDERS INTRACEREBRAL HEMORRHAGE (ICH) ADMITTING ORDERS BLOOD PRESSURE Goal BP __________________________ MANAGEMENT
Nicardipine (Cardene®) 5 mg/hr (50 ml/hr), increase rate by 2.5 mg/hr every 5 mins (up to 15
mg/hr), once goal Blood Pressure is reached decrease rate to 3 mg/hr
Labetolol (Normodyne®) 10 mg IV bolus x 1. If ineffective, start Labetolol IV at 2 mg/min and
titrate to goal Blood Pressure (maximum dose 300 mg or 5 mg/min)
Esmolol (Breviploc®) 500 mcg/kg IV loading dose over one minute then maintenance IV at 50
mcg/kg/min titrate to goal Blood Pressure (maximum dose of 200 mcg/kg/min)
Nitroprusside (Nipride®) 0.25 mcg/kg/min IV maximum dose of 4 mcg/kg/min titrate for
Nitroglycerin 5 mcg/min IV titrate until goal BP is reached (maximum 100 mcg/min) Other:_______________________________________________________________________
PRNs: Hydralazine 5 mg IV every 4 hours prn SBP is above ___________________ Enalapril 0.625 mg IV every 6 hours prn SBP is above ___________________ Enalapril 1.25 mg IV every 6 hours prn SBP is above ___________________ Other:_______________________________________________________________________ All to be done STAT Lipid Panel
Serum osmolality prior to each dose of Mannitol
Daily Labs CBC PT with INR, PTT Basic Metabolic Panel Serum osmolality ABG if intubated Daily portable Chest X-ray, if intubated Other:________________________________________________________________________ MEDICATIONS
Mannitol 1 gm/kg IV x 1 dose, then 0.5 gm/kg IV every 6 hours (Hold for osmolality if above
Dulcolax 10 mg PR b.i.d. prn constipation Other:_______________________________________________________________________ Pain Acetaminophen 650 mg PO PR every 4 hours prn for mild pain or temp is above 100.5° Hydrocodone 5/500 1 tab PO every 4 hours prn for moderate pain Hydrocodone 5/500 2 tabs PO every 4 hours prn for severe pain Morphine 1 mg IV every 1 hour prn moderate pain Morphine 2 mg IV every 1 hour prn severe pain Fentanyl 50 mcg IVP every 1 hour prn moderate pain Fentanyl 100 mcg IVP every 1 hour prn severe pain *DO NOT EXCEED 4000 MG ACETAMINOPHEN IN 24 HOURS* INTRACEREBRAL HEMORRHAGE (ICH) ADMITTING ORDERS INTRACEREBRAL HEMORRHAGE (ICH) ADMITTING ORDERS MEDICATIONS CONTINUED
Lorazepam (Ativan®) 2 mg IV every 15 min prn seizures x 2 doses, then call MD Fosphenytoin (Cerebyx®) loading dose 1 gm IV, then 100 mg IV every 8 hours Levetiracetam (Keppra®) 500 mg PO or IV b.i.d. Other:_________________________________________________________________
Peptic Ulcer Prophylaxis Famotidine (Pepcid®) 20 mg IV every 12 hours Famotidine (Pepcid®) 20 mg PO every 12 hours if tolerating PO Pantoprazole (Protonix®) 40 mg IV daily Pantoprazole (Protonix®) 40 mg PO daily if tolerating PO Antiemetics Ondansetron (Zofran) 4 mg IV every 6 hours prn nausea/vomiting Other:__________________________________________________________________ Coagulation Management Vitamin K 10 mg in 100 ml NS over 1 hour Vitamin K 0.2 mg 0.5 mg 10 mg SQ IV Once daily x 3 days Recombinant activated Factor VII 80 mcg/kg x1 160 mcg/kg x1 given within 4 hours of ICH For elevated PT/INR of ________: FFP 2-6 units or Factor VII 4.8 mg For INR above 1.3, 3 units of FFP For Fibrinogen less than 200: Cryoprecipitate 10 units 20 units For platelets below 100,000: 2 units single donor platelets Other:__________________________________________________________________ Electrolyte Replacement Potassium 3.8-4, KCl 20 meq IV infusion over 2 hours x 1 Potassium below 3.8, KCl 40 meq IV infusion over 4 hours x 1 Magnesium 1-1.5, Magnesium Sulfate 4 gm IVPB to run over 2 hours x 1 Magnesium 1.6-2, Magnesium Sulfate 2 gm IVPB to run over 2 hours x 1 DIAGNOSTIC All to be done ASAP CT of brain without contrast CT Angiogram of the head with contrast MRI of brain MRA of brain Portable CXR 12 lead EKG Carotid Doppler 2D echocardiogram EEG CONSULTS
Physical Therapy Evaluation & Treatment Occupational Therapy Evaluation & Treatment Speech Therapy for Swallow Evaluation & Treatment Speech Therapy for Speech & Language Evaluation & Treatment Dietitian Case Management for discharge options
INTRACEREBRAL HEMORRHAGE (ICH) ADMITTING ORDERS INTRACEREBRAL HEMORRHAGE (ICH) ADMITTING ORDERS
Give patient/family/caregiver Stroke Education Packet on admission
EDUCATION
Provide Smoking Cessation information if a current smoker or has smoked in past 12 months Diet Exercise Weight Management Medication Diabetic Teaching (if Diabetic)
Approved: ER/JOC _____; Forms 10/13/11; P&T 10/20/11; PIC 10/17/11; MEC 10/19/11; Board 10/25/11 Form # 703.047 Rev 7/12
E’ COMPARSA LA VARICELLA E’ una malattia molto frequente e molto contagiosa: è sufficiente un’ora di permanenza nella stessa stanza con una persona affetta, per contrarre questo virus, della famiglia degli Herpes. L’incubazione è di 15-21 giorni dal contatto, poi comincia ad arrivare la febbre quasi subito seguita dalla comparsa dei piccoli brufolini rossi pruriginosi che in brev