PHYSICIAN ORDERS TRANSIENT ISCHEMIC ATTACK (TIA) OBSERVATION

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1 SCREENING- ABCD-2 Score The ABCD2 score is a risk assessment tool designed to improve the prediction of short-term stroke risk after a transient ischemic attack (TIA). Higher ABCD2 scores are associated with greater risk of stroke during the 2, 7, 30, and 90 days after a TIA. The ABCD2 score is calculated by summing up points for five independent factors SCORE SYMPTOMS PRESENT DURING TIA EPISODE Age greater than or equal to 60 1 Systolic BP greater than 140 mmhg and/or Diastolic BP greater than or equal to 90 mmhg 1 Unilateral weakness 2 Speech disturbance without weakness 1 Duration of symptoms: Less than 10 minutes minutes 1 Greater than or equal to 60 minutes 2 Diabetes 1 Total ABCD2 Score: Transient Ischemic Attack (TIA) Outpatient Observation Algorithm YES Signs and Symptoms of Stroke resolved in 60 minutes or less NO ABCD-2 Score less than or equal to 4 NO Admit inpatient YES TIA Outpatient Observation DATE TIME PHYSICIAN S SIGNATURE Page 1 of 5 (09/01/11)

2 1. ALLERGIES/REACTIONS: 2. Outpatient Observation for (symptoms): 3. LEVEL OF CARE: Med Surg Tele 4. PREFERRED LOCATION (UNIT/SERVICE): 5. ACCEPTING PHYSICIAN: 6. NUTRITION: NPO until swallow screen completed by RN. If failed, obtain speech consult for swallow evaluation and treatment as appropriate. NPO Regular Cardiac Diabetic ADA calories Other: 7. ACTIVITY: Up with assistance or 8. LABS: MRSA PCR Screen and contact precautions, if indicated, per MRSA Screening Protocol Culture suspected infection per Protocol Fasting Blood Sugar Hgb A1C (if fasting blood sugar greater than 110)** Fasting Lipid Panel** Other: 9. DIAGNOSTICS: (Reason for test: TIA) MRI brain with and without contrast MRA head and neck with contrast Echocardiogram with bubble study to be read by available cardiologist or Dr. Carotid Ultrasound (If unable to do CTA or MRA) ECG (If not completed in ED) Page 2 of 5

3 10. GLUCOSE MANAGEMENT: Baseline Hgb A1C (do not draw if patient received blood transfusion within 3 months) A. Correction Subcutaneous Insulin: Provider to Check Insulin Choice AND Dosing Level Regular Insulin (Novolin R/Humulin R) Insulin Aspart (Novolog)/Insulin Lispro (Humalog) Fingerstick blood glucose before meals and at bedtime or if NPO check every 6 hours If fingerstick blood glucose greater than 180 mg/dl times 2 consecutive checks increase correction insulin scale to next higher dose. When at high dose insulin and if blood glucose remains greater than 180 mg/dl, contact physician to transition patient to Glycemic Control- Insulin Infusion Physician Order #824 or Glycemic Control- Subcutaneous Addendum Physician Order #825. Blood Glucose (mg/dl) Low Dose for Total Daily Dose less than 40 Units/Day B. HYPOGLYCEMIA PROTOCOL (Blood glucose less than 70 mg/dl): If patient awake and able to take PO give 4 oz of clear regular soda (i.e. Sprite) If patient awake and unable to take PO give 25 ml (1/2 amp) 50% dextrose in water (D 50 W) IV push If patient obtunded (due to hypoglycemia) give 50 ml (1 amp) 50% dextrose in water (D 50 W) IV push Recheck blood glucose in 15 minutes. If blood glucose less than 70 mg/dl, repeat above treatment. Recheck blood glucose every 30 minutes until greater than or equal to 80 mg/dl. If glucose remains less than 70 mg/dl after 2 doses of soda/dextrose, then notify provider C. Surgeon to handle glucose management OR Hospitalist to consult for glucose management FIT GHC CHC Medium Dose for Total Daily Dose Units/Day 11. MEDICATIONS: Complete Medication Reconciliation Nursing to complete Nurse Initiated Vaccine Assessment Order # Nurse may initiate Over the Counter Patient Care Products Physician Order #767 High Dose for Total Daily Dose greater than 80 Units/Day unit 3 units 4 units units 6 units 8 units units 9 units 11 units units 12 units 15 units Greater than 350 Notify MD 10 units 15 units 18 units Page 3 of 5

4 11. MEDICATIONS: (Continued) Antiplatelet Agents: Aspirin 81 mg PO daily. If patient fails swallow screen or unable to take oral medication, THEN administer Aspirin 300 mg rectal suppository daily. Aspirin 325 mg PO daily. If patient fails swallow screen or unable to take oral medication, THEN administer Aspirin 300 mg rectal suppository daily. Clopidogrel (Plavix) 75 mg PO daily Clopidogrel (Plavix) 300 mg PO times one dose Clopidogrel (Plavix) 600 mg PO times one dose Dipyridamole ER 200 mg/ Aspirin 25 mg (Aggrenox) PO twice daily Statin Therapy**: Simvastatin: If taking amiodarone, verapamil, or diltiazem chronically limit dose to 10 mg nightly; if taking amlodipine or ranolazine, limit dose to 20 mg nightly. If patient requires more simvastatin use rosuvastatin. Simvastatin (Zocor) 10 mg PO HS Simvastatin (Zocor) 20 mg PO HS Simvastatin (Zocor) 40 mg PO HS Rosuvastatin (Crestor) 10 mg PO HS Rosuvastatin (Crestor) 40 mg PO HS (Intensive statin therapy) Do not give statin medication due to: Reason (Required): VTE Prophylaxis: Sequential compression device (SCD) unless contraindicated Do not apply sequential compression device due to: Reason (Required): Nicotine Replacement: Nicotine Replacement Protocol per Nicotine Replacement Physician Order #616 Provide smoking cessation information to patient and document on education record Other Medications: 12. INTRAVENOUS FLUIDS: Saline lock 0.9% sodium chloride (Normal Saline) at ml/hour Other: 13. TREATMENT: Vital signs per unit protocol Vital signs every hours times hours, then per unit protocol Neuro Checks: (Use Neurological flow sheet for assessment) Neuro checks every hours times hours, then every hours Notify physician for any change in neurological assessment Page 4 of 5

5 14. DISCHARGE PLANNING: Care Management for discharge planning (including possible DSHS application and medication assistance) Stroke education ** **Indicates a Stroke Performance Measure. Initiate measures as appropriate; if not appropriate, document reason in progress notes. This is required by Joint Commission for Primary Stroke Center Certification, American Stroke Association, and CMS guidelines.** 15. Emergency Department physician signature and observation order follow-up: Check either A or B. A. The undersigned has personally discussed the case with Dr. at (time), who agrees to be responsible for the patient s care. These Observation Orders have been read back to and accepted by the accepting physician and are to continue unchanged. It is not necessary for the RN to contact the accepting physician to review these orders. Please contact the accepting physician for any questions, changes in patient condition or vital signs, or requests for further orders. DATE TIME ACCEPTING PHYSICIAN TORB/ ED PHYSICIAN S SIGNATURE DATE TIME ACCEPTING PHYSICIAN CO-SIGNATURE B. The undersigned has personally discussed the case with Dr. at (time), who agrees to be responsible for the patient s care. RN must contact accepting physician after nursing assessment to update the patient s condition including vital signs, and to review these Observation orders with the accepting physician. Any changes or additions will be written on a separate physician order set/sheet. DATE TIME EMERGENCY DEPARTMENT PHYSICIAN S SIGNATURE Page 5 of 5

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