+ + Pt. Identifier

ICU Intracerebral Hemorrhage Admission Orders Page 1 of 4

STATUS : See Initial Order Set - Patient Status already completed by MD Abbreviations Transfer to SICU Transfer to CICU Transfer to CVICU Transfer to ICU

DIAGNOSIS: ntracerebral (parenchymal) Hemorrhage I

DO USE Consult Dr. ______re: ______to see: STAT / TODAY / IN AM

NOT

USE Consult Dr. ______re: ______to see: STAT / TODAY / IN AM

Consult therapy: Physical Occupational Speech Wound Care re: ______

Q.D..QD Rehab Eval – Case Management / Inpatient Rehab Daily q.d.,qd Palliative Care re: Goals of care or ______

ALLERGIES/ PRECAUTIONS: If Allergic to PCN/Cephalosporin or carbapenem - Reaction: Q.O.D. Every ___ Anaphylaxis/Breathing difficulties ___ Urticaria ____ Delayed Rash ___ Unknown ____ Other QOD Other Reaction investigated & Patient may receive Cephalosporin or Carbapenem: ____ Yes _____ No q.o.d. Day qod See DNR Order Full Code CODE STATUS:

NURSING:

U  Vital Signs Q 1 hr with continuous pulse oximetry Units u  Refer to BP management and parameters on pg 4

 Notify MD for

HR < (50) _____ or > (120) ______; RR > (30) _____; Temp > (101) ______;

No O2 sats < (90%) ______on ______; Urine Output < (1cc/kg/hr) ______or > ______Trailing 2 mg Zero  Initiate Nursing Stroke Guidelines for Care (found on Careline with Medical Record forms)  Notify Stroke Team (RRT) on admission  Neuro Checks Q (2) ______hrs and any change in patient condition Lack of  Delirium Assessment Q shift Leading 0.2 mg Zero  Activity : Bedrest with HOB >30 unless contraindictated : ______

 Initiate the ICU Pressure Ulcer Prevention Protocol (includes daily weights)

Morphine  Strict I & O: Place Foley Catheter with drainage to gravity MS Sulfate  Oral Care Q 2hr Magnesium Sulfate Lacrilube to both eyes Q 4hrs and PRN Diet: NPO until RN/LPN swallow screen. If swallow screen failed, notify MD, consult SLP and Keep NPO

Clear Liquid NPO x ice chips Regular ______Morphine MS04 Sulfate  Consult dietitian for nutritional content assessment and management OG: continuous low suction or clamped/check residuals Q4hr

GLUCOSE MANAGEMENT:

Magnesium  Initiate “ICU Blood Glucose Treatment Protocol”

MgSO4 Sulfate  Initiate Hypoglycemia protocol if BG < 70 and notify MD VTE RISK AND PREVENTION: HIGH RISK  Bilateral Sequential Compression Devices – SCDs

 Anticoagulation Contraindicated because: High risk of bleeding AM Labs/Imaging:  Fasting Lipid Panel CBC BMP PT/INR Portable CXR - Indication: (respiratory failure) ______

MD Signature: Date: Time: Origin: 4/13 RN Signature: Date: Time: Revised: 7/13; 10/14;

4/16

*1024*

Pt. Identifier

ICU Intracerebral Hemorrhage Admission Orders Page 2 of 4

IMAGING:

Abbreviations ECG 12 lead STAT 2-D Echo with color doppler (read by ______) Indication for echo: ______Indication for any of below studies ordered: Intracerebral (Parenchymal) Hemmorrhage DO MRI Brain without Contrast (use if CVA/TIA or stroke like symptoms) NOT USE MRI Brain with and without Contrast (use if infection, tumor, MS, cranial nerve palsy suspected)

USE CT Head with and without Contrast (use if infection or tumor suspected)

Carotid Ultrasound (bilateral) Cerebral Angiogram (MD to contact Interventional Radiologist to discuss) Q.D..QD Daily q.d.,qd **Recommend Vascular Head and Neck Imaging be ordered at the same time

STAT LABS: (if not already initiated in ED)  CBC  PT/INR & PTT BMP D - dimer Q.O.D. Every Blood cultures x 2 LFTs CMP Sed rate QOD Other Sputum gram stain & cult Lactate level BNP Ionized Calcium q.o.d. Day

qod UA and Culture TSH, free T3, free T4 Mg  Hbg A1 C

Hgb/Hct every _____ hrs x ______Phosphorous

CK/CK-MB & Troponin I STAT then Q _____ hrs x ______

U Units u MEDICATIONS AND IV FLUIDS ■ Place medication reconciliation forms on chart for MD to complete Initiate “Standard Mag and Potassium Replacement Protocol” – DO NOT use if Creat ≥ 2.5 IVF Rate cc/hr Additive No NS @ ______Trailing 2 mg D5W @ ______Zero D5 0.45NS @ ______D5 0.9 NS @ ______Other: ______@ ______

Lack of Leading 0.2 mg COAGULATOPATHY Zero Refer to “Warfarin Reversal Orders for Intracranial Hemorrhage” Refer to “Dabigatran Intracranial Reversal Orders” Packed Red Blood Cells (RBCs)

Morphine Type and Screen Type and Crossmatch for ______units Sulfate MS If type and Crossmatch or Screen has been performed in the last 72 hours, only the crossmatch will be performed. Magnesium

Sulfate Transfuse _____ units, each over ______hours Options: Leukopoor CMV Irradiated Indication: (Check all that apply) HCT ≤ 21% or Hbg ≤ 7 gm/dL

Normovolemic; with the need for increased oxygen carrying capacity Morphine MS04 Sulfate Platelets

Transfuse _____ units, each over ______hrs Options - CMV Irradiated HLA X-Matched Indications: 3

Plt ct ≤ 10,000/mm prophylactically in a patient with failure of platelet production

Magnesium Plt ct ≤ 20,000/mm3 with signs of hemorrhagic diasthesis (petechiae, mucosal bleeding) MgSO4 Sulfate 3 Plt ct ≤ 50,000/mm with active hemorrhage Plt ct ≤ 50,000/mm3 with invasive procedure (recent, in-progress, planned) Plt ct ≤ 100,000/mm3 with neurologic procedures or CV surgery in the presence of significant bleeding. Plt dysfunction as documented by: ______

Origin: 4/13 Fresh Frozen Plasma (FFP)

Revised: 7/13; 10/14; Transfuse _____ units, each over ______hrs 4/16 Indications: Abnormal coagulation studies and significant hemorrhage *1024* Emergent reversal of warfarin PTT > 75 seconds or INR > 2.5 Clinically observed coagulopathy. Specify circumstance: ______

MD Signature: Date: Time:

RN Signature: Date: Time:

Pt. Identifier

ICU Intracerebral Hemorrhage Admission Orders Page 3 of 4

RESPIRATORY Abbreviations  Call MD for SpO2 ≤ 90 % ABG STAT Nasal Cannula AND/OR Face Mask at _____ L/min or _____FiO2 Wean for SpO2 ≥ 93 % DO NOT USE Initiate “Bronchodilator Protocol” Initiate “NonInvasive Ventilation Protocol”

USE MECHANICAL VENTILATION

Mode ______ ABG 30 minutes after intial settings Q.D..QD Daily Rate ______bpm TV ______cc  ABG PRN acute respiratory distress (notify MD of results) q.d.,qd

PEEP ______cmH2O  Daily Assessment per the Weaning From Mechanical Pressure Support ______cmH2O Ventilator Protocol FI02 ______titrate to a Sp02 ≥ 92%  Notify MD for: ______

Q.O.D. Every QOD Other q.o.d. Day qod SEDATION / ANALGESIA FOR MECHANICAL VENTILATION: . DO NOT ADMINISTER ANY OF THE BELOW INFUSIONS - IF PATIENT IS EXTUBATED . ALL INFUSION ORDERS WILL EXPIRE AFTER 72 HOURS; PHYSICIAN MUST REWRITE . Maintain level 3-4 on the modified Ramsey sedation scale (MRSS) Q 2h and document U Units u . Wean to a MRSS of 2 at least Q 24hrs; Assess neurological status & weaning ability Restart infusion at half of previous dose and titrate to desired MRSS . Notify MD for MAP < 65mmHg or if unable to maintain sedation within dosage range SEDATION: No Propofol infusion at 5 micrograms/kg/minute Trailing 2 mg . Titrate by 5 micrograms/kg/min Q 5min to maintain ordered MRSS (Max of 50micrograms/kg/minute) Zero . Change tubing Q 12hrs . Serum triglyceride level at start of infusion and Q 72hrs while on propofol (notify MD if > 300 mg/dl) OR Lack of Midazolam infusion (100 mg/100 mL 0.9% NaCl) at 1 mg/hr Leading 0.2 mg . Titrate by 0.5 mg/hr Q 30 min to maintain ordered MRSS (Max of 10 mg/hr) Zero OR Midazolam 1-5 mg IV Q 1hr PRN to maintain ordered MRSS

ANALGESIA: Morphine Morphine 1-2 mg IV Q1hr PRN mild pain; 3-4 mg IV Q 1hr PRN moderate pain; 5 mg IV Q 1hr PRN severe pain MS Sulfate Magnesium OR

Sulfate Fentanyl infusion (2.5 mg/250 mL 0.9% NaCl) at 50 micrograms/hr ■ Titrate by 25 micrograms/hr Q 15 min to maintain analgesia goal (Max of 300 micrograms/hr) OR

Fentanyl IV ____micrograms Q ____ hours to maintain analgesia goal

Morphine

MS04 Sulfate

MD Signature: Date: Time:

Magnesium MgSO4 Sulfate RN Signature: Date: Time:

Origin: 4/13 *1024* Revised: 7/13; 10/14; 4/16

Pt. Identifier

ICU Intracerebral Hemorrhage Admission Orders Page 4 of 4

BLOOD PRESSURE MANAGEMENT IN ICH WITHOUT EVIDENCE OF ELEVATED ICP

Abbreviations Select BP management parameter: SBP OR MAP Goal: SBP range < 160 but > 130 mmHg or ______mmHg MAP range < 110 but > 80 mmHg or ______mmHg DO NOT USE

USE  The Below Medication Management / Titration will be based on 2 separate BP measurements 5 min apart  Continuous infusion administration requires Arterial line placement for BP monitoring

Q.D..QD Daily q.d.,qd

For SBP > 180 mmHg OR MAP > 130 mmHg initiate  NiCARdipine (Cardene) 25 mg / 250 mL 0.9% NaCl . Starting dose 5 mg/hr Q.O.D. Every . Titrate 2.5 mg/hr Q 15 min to maintain BP goal parameters QOD Other q.o.d. Day . Notify MD if patient requires 15 mg/hr (Max dose) and unable to meet BP goal parameters qod IF SBP > 160 mmHg OR MAP > 110 & Max dose Nicardipine (15mg/hr) reached & HR > 60 ADD: IF UNABLE TO ADD Labetalol DUE TO HR < 60 – Notify MD FOR ORDERS Labetalol (Trandate) Bolus U Units u . 10 mg slow IVP (over 2 mins) . May repeat Q 5 min PRN SBP (>160 mmHg) ____ mmHg OR MAP (> 110 mmHg) ____ mmHg HR must be > 60 bpm . Max dose 300 mg / 24 hrs No Trailing 2 mg . Notify MD if unable to meet BP goal parameters Zero

Start Labetalol infusion if response to bolus dose is adequate BUT BRIEF & HR > 60: Labetalol infusion 200 mg in 100 mL Lack of Leading 0.2 mg . Start IV infusion: 1mg / min Zero . Increase by 1mg/min Q 15 min . Titrate to maintain BP goal parameters

. Max infusion rate of 8mg/min ( Max dose of Labetalol 300mg/24 hrs, including boluses) Morphine MS Sulfate . Notify MD if unable to meet BP goal parameters Magnesium Sulfate Other Medication Options: ______IV infusion Bolus

Morphine Titration: ______MS04 Sulfate Max Infusion / Dose: ______Notify MD: ______

Magnesium MgSO4 Sulfate BLOOD PRESSURE MANAGEMENT IN ICH WITH EVIDENCE OF ELEVATED ICP Goal : CPP > 60 mmHg but < 70 mmHg AND ICP < 20 mmHg  Refer to “ICP Management Orders” for care and monitoring

Origin: 4/13 MD Signature: Date: Time: Revised: 7/13; 10/14;

4/16 RN Signature: Date: Time:

*1024* Patient Identifier

Nursing Guidelines of Care for the Hemorrhagic Stroke Patient page 1 of 2 Inclusion criteria: All patients with Subarachnoid and Intracerebral Hemorrhages

Stroke Team • Confirm Notification of the Rapid Response/Stroke Team • NIHSS on admission and follow-up 24hrs post presentation by RRT • Repeat NIHSS prior to if length of stay is less than 24 hrs Supportive Care and Treatment of Acute Hemorrhagic Stroke  Assessment • Neuro Checks and Vital signs as ordered and per patient status. • Notify physician:  For any signs and symptoms of neurological deterioration, including: o Change in level of consciousness- lethargy, sedation, increased confusion, agitation o Neurological deficits, new or increased o Nausea and vomiting, new onset o Headache, new onset or worsening  Vital Signs: SBP > 160 or < 140 Heart rate > 100 or < 50 Temperature > 100.5 F0 O2 sats < 90% on room air or RR > 24 • Goal for blood glucose is <180mg/dL  VTE Prevention: High risk for DVT formation; anticoagulation may be contraindicated d/t high risk of bleeding • Complete Daily VTE Assessment • SCDs unless contraindicated  Activity/Safety • Nursing Swallow Screen prior to first po intake, including medications. If Failed: Keep NPO, notify MD and SLP for swallowing evaluation. If Passed: Implement diet order. • Activity as ordered by the physician • Turn and position at least every 2 hours while in bed if unable to move self • Complete Daily Fall Risk Assessment  Nursing Screens (nursing-initiated consults that do not require a physician order) Case management/Discharge Planner Physical Therapy Occupational Therapy Speech/SLP if Nurse Swallow Screen failed, Speech Impaired or has Cognitive Deficits Dietician if new diagnosis of DM, Hgb A1C > 9, or BMI > 30  Patient/Caregiver Stroke Education • Provide and Review Stroke Education Packet • Document teaching under ‘patient education’ tab • Stroke Education Packet should include all of the below: Personalized Risk Factor Modification (Smoking Cessation, DM, HTN, Cholesterol, Sleep Apnea, Obesity) Warning Signs and Symptoms of stroke (FAST) How to call EMS *1357* Medication Instructions/Compliance Follow-up Appointment with Physician Origin: 10/13

Implemented By , RN Date/Time Patient Identifier

Nursing Guidelines of Care for the Hemorrhagic Stroke Patient page 1 of 2 Inclusion criteria: All patients with Subarachnoid and Intracerebral Hemorrhages

Nursing Information Only • NIHSS (National Institute of Health Stroke Scale) is a noninvasive and valid assessment tool used to evaluate neurological status- reliable predictor of infarct size, location, and stroke severity/disability o 0= No Stroke/No Deficits o 1-4= Minor Stroke/Mild Deficits o 5-15= Moderate Stroke/Moderate Deficits o 15-20= Moderate/Severe Stroke/Major Deficits o 21-42= Severe/Devastating Stroke/Major Deficits • Blood pressure should be monitored and controlled to balance the risk of stroke, hypertension-related rebleeding and perfusion to the brain. • Patients with hemorrhagic strokes may be a greater risk for rebleeding, hydrocephalus, cerebral vasospasms, and seizures. • Avoiding hypovolemia and hyponatremia is recommended to prevent volume contraction, vasospasms, and increased brain tissue damage. • Hyperthermia in stroke patients may damage penumbra and increase brain damage. • Sources for elevated temperature should be identified & treated. Administer antipyretic (ex. Tylenol) as ordered to prevent hyperthermia. • It is recommended that O2 @ 2-4L/NC should be administered to maintain O2 sats > 94% but a physician order for O2 therapy is required. O2 is NOT recommended for non-hypoxic patients with acute ischemic stroke. • Persistent hyperglycemia (>200 mg/dL) in the first 24 hours of acute stroke has been shown to result in worse patient outcomes than those with normoglycemia. Goal for blood glucose < 180 mg/dL. • If glycemic order set is implemented, monitor closely to prevent hypoglycemia (< 60mg/dL). • HOB elevation is recommended for patients at risk for ICP & aspiration pneumonia. • Majority of stroke patients will have some sort of swallowing difficulty and may be prone to aspiration pneumonia. • Cognitive deficits may include being impulsive, unaware of safety risks, poor or short term memory problems etc. • Monitor for fall risk. Stroke patients may be prone to being impulsive or unaware of deficits, increasing likelihood for falls • Follow up CT/MRI of head is recommended at 24 hrs after tPA before starting anticoagulants or antiplatelet therapy.

Additional Stroke Resources Stroke Resource Center on Nurses Portal AHA/ASA Guideline: Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage http://stroke.ahajournals.org/content/40/3/994.full American Association of Neuroscience Nurses (AANN) Clinical Practice Guidelines @ www.aann.org Care of the Patient with Aneurismal Subarachnoid Hemorrhage American Heart/American Stroke Association @ www.heart.org Free NIHSS Certification @ www.ems4stroke.com *1357*

Implemented By , RN Date/Time Origin: 10/13

Reference Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel AB, Rosenwasser RH; American Heart Association.(2009). Guidelines for the management of aneurysmal subarachnoid hemorrhage. Stroke. doi: 10.1161/STROKEAHA.108.191395.