Unique Plan Description: Stroke Thrombectomy without TPA, (MH)
Plan Selection Display: Stroke Thrombectomy without TPA, (MH)
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2023-12-11 07:42:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-03-04 07:44:36
Available at all facilities: No

Stroke Thrombectomy without TPA, (MH)
Admit/Discharge/Transfer
	Admit to Critical Care Inpatient Status (MH)
		T;N, Anticipated LOS 2 midnight or more
Vital Signs
	Vital Signs
		Routine post op
Diet
	NPO
		Strict NPO, If fails nurse swallow screening, keep NPO until speech therapy evaluation. If no dysphagia, advance diet to General
	Advance Diet as Tolerated
		T;N
			Comment: to general diet if patient has passed nurse swallow screen
Laboratory
	Lipid Panel
		T+1;0400, Routine, spec type = Blood
	CMP
		T+1;0400, Timed, spec type = Blood
	INR - MH/WH/JE
		T+1;0400, Timed, spec type = Blood
	Hemoglobin A1C
		T+1;0400, Routine, spec type = Blood
	TSH
		T+1;0400, Routine, spec type = Blood
Diagnostic Tests
	CT Head w/o Contrast
		T+1, 0600, Routine, CVA
			Comment: Post Thrombectomy, may be replaced by MRI
	MRI Brain w/o Contrast
		Routine, Cerebrovascular Accident/Stroke
	Echo Resting w Bubblestudy
		T+1;0400, Routine, Indication: Cerebral vascular accident
IV Solutions
	Sodium Chloride 0.9%
		1,000 mL, IV, 50 ml/hr
		1,000 mL, IV, 75 ml/hr
		1,000 mL, IV, 100 ml/hr
		1,000 mL, IV, 125 ml/hr
		1,000 mL, IV, 150 ml/hr
		1,000 mL, IV, 20, ml/hr
Medications
	TICI Score Post Procedure
		SBP < 180/105 TICI Grade 2a or lower
	labetalol  injection
		10 mg 2 mL, Injection, IV Push, Q10MIN, PRN, see comment, Duration: 2 Dose(s)/Time(s)
			Comment: To Keep SBP <180/105.  Give over 2 minutes.  Notify MD if labetalol 10mg IV q10min PRN x2 doses is not effective
	TICI Score Post Procedure
		SBP < 140/100 TICI 2b or greater
	labetalol  injection
		10 mg 2 mL, Injection, IV Push, Q10MIN, PRN, see comment, Duration: 2 Dose(s)/Time(s)
			Comment: To Keep SBP< 140/100. Give over 2 minutes.  Notify MD if labetalol 10mg IV q10min PRN x2 doses is not effective
	aspirin
		81 mg, Tablet-Enteric-Coated, By Mouth, Once, NOW
			Comment: if NPO may switch order to aspirin 300mg rectal supp
		81 mg, Tablet-Enteric-Coated, By Mouth, DAILY, T+1;0900
			Comment: if NPO may switch order to aspirin 300mg rectal supp
	Plavix
		75 mg, Tab, By Mouth, DAILY
	Tylenol
		650 mg, Tab, By Mouth, Q4H, PRN see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
		650 mg, Suppository, RECTALLY, Q6H, for see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
	Pepcid
		20 mg, Injection, IV Push, BID
			Comment: convert to PO when taking PO
Patient Care
	Resuscitation Status
		T;N, Full Code
		T;N, No Code
	Neurological Assessment-Focused
		T;N, Q1H
			Comment: Routine Post op, then q1h
	Complete NIH Stroke Assessment
		T;N, Q12H-Start of Shift, 4, Dose(s)/Time(s)
			Comment: Notify provider if worsening neurological assessments or NIHSS score increases
	Complete Nurse Swallow Screen
		T;N
			Comment: if fails swallow screening, keep NPO until speech therapy evaluation. If no dysphagia, advance to general diet as tolerated.
	Notify MD
		if temp >100.4, 	if SaO2 <94%, if BP outside ordered parameters
			Comment: if LDL >70 and not already on statin, if patient diabetic and HGB A1C is >5.6.
	Bladder Scan
		Q4H, unable to void, every 4 hours if no void, or is uncomfortable.
	Straight Catheter
		bladder scan > (see comment)
			Comment: 500ml.
	Incentive Spirometer
		Q1H
	Cough, Deep Breathe
		QHAWAKE
	Patient Education
		DAILY, Instructions: Personal risk factors, warning signs of stroke, activation of EMS, need for follow up after discharge, medications at discharge.
		Once, Instructions: Regarding stroke. Provide patient and family folder with Krames stroke materials on admission
	Cardiac Telemetry Monitoring
		Telemetry Indications: Stroke/TIA
			Comment: Stroke
	Sequential Compression Device
		T;N, Apply, Once
			Comment: contraindicated with PVD. Knee High
	Complete PHQ-9
		T;N
			Comment: Prior to discharge. Notify attending provider if score >5
	Smoking Cessation Education
		T;N
			Comment: if active smoker within past 1 year.
Therapies
	Consult Physical Therapy, Evaluate and Treat
		Reason to See: Stroke
			Comment:  within 24 hours of admission.
	Consult Occupational Therapy, Evaluate and Treat
		Reason to See: Stroke
			Comment: within 24 hours of admission.
	Consult Speech Language (MH), Evaluate and Treat
		Stroke
			Comment: Evaluate within 24 hrs, MBS if appropriate. Order diet as recommended by Methodist Speech Therapy; call 402-354-4461 and leave message for consult
Consults/Follow-up
	Consult Social Work
		Discharge Planning
	Consult Diabetes Educator
		Needs Diabetic Assessment
			Comment: Needs Diabetic Assessment if A1C >5.6 (pre diabetic) or diabetic
	Consult Neurologist
		Reason for Referral: Diagnosis: Stroke, Refer to/Consult with: neurologist on call
	Consult Intensivist
		Reason for Referral: Mechanical Thrombectomy, Refer to/Consult with: MD: MPC Pulmonary Medicine Specialists
	Consult Physical Medicine (Rehab)
		Reason for Referral: Diagnosis: Stroke, Refer to/Consult with: Physical Medicine & Rehabilitation
			Comment: Place the patient on Dr. Jim Kult's list and call the Admission Coordinator of Rehab at 402-354-4408 and leave a message.
	Consult Dietitian
		Regarding: Nutrition Assessment, Dietitian Assess Only

nicardipine (Cardene) Protocol EKM
IV Solutions
	niCARdipine 25 mg/NS 250 mL
		25 mg, EVERY BAG, 5 mg/hr, T;N
		250 mL, IV, Routine, Start: T;N, Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy.  If hypotension or tachycardia occurs, discontinue the infusion and notify provider.  IV may be re-initiated after weaning within 12hours, re-initiate at the dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
	niCARdipine 20mg/NS 200mL
		200 mL, IV, STAT, Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy. Reduce by 2.5mg/hr every 15 minutes.   If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
		20 mg, EVERY BAG, 5 mg/hr, T;N
	nicardipine 20mg/NS 200mL premix
		200 mL, IV, STAT, Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy. Reduce by 2.5mg/hr every 15 minutes.   If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
		20 mg, EVERY BAG, 5 mg/hr
Patient Care
	IV-Restart
		T;N, Q12H
			Comment: if peripheral site is used while on nicardipine

Oxygen Protocol
Therapies
Respiratory Therapy
	Oxygen Therapy
		T;N
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID

Peripheral Lock - Access
Medications

	sodium chloride 0.9% flush injectable soln
		10 mL Syringe IV PUSH BID
		10 mL, Syringe, IV PUSH, Q5MIN, PRN, IV line flush
	lidocaine 1% injectable solution (MH/WH/FH)
		0.1 mL, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start
	sodium chloride bacteriostatic 0.9% injectable soln
		0.1 mL, Injection, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start, use if patient has lidocaine allergy.
	Sodium Chloride 0.9% IVPB Flush
		25 mL, IVPB, Q1H, PRN, IV line flush, 5 min(s)
			Comment: Use if medication not compatible with primary line or there is no primary line;  infuse 25mL.
Patient Care
	Peripheral Lock-Insert
		T;N

VTE Prophylaxis
Medications
	Lovenox
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T;N
			Comment: (CrCl>30) Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T;N+480
			Comment: (CrCl>30) Start 8 hours after admission. Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T+1;0900
			Comment: (CrCl>30) Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
	HEParin 5000 units/mL SUBCUTANEOUS
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T;N
			Comment: VTE Prophylaxis
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T;N+480
			Comment: Start 8 hours after admission. VTE Prophylaxis
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T+1;0600
			Comment: VTE Prophylaxis
Patient Care
		Sequential Compression Device and Anti Embolism Device orders will not suppress the VTE Advisor(NOTE)*
	Sequential Compression Device
		T;N, Apply, Once
	Anti Embolism Stockings
		T;N, Apply, Once
			Comment: knee high
	VTE Prophylaxis Contraindication
		High Risk of Bleeding
		Procedure Planned
		ASA order meets prophylaxis requirement
		If patient is low risk or further evaluation needed, complete advisor:(NOTE)*
	VTE Advisor
		Medical

Pain Constipation Nausea Protocol </= to 65 EKM
Medications
		Select only one medication in each category(NOTE)*
Mild Pain
	Tylenol
		650 mg, Tab, By Mouth, Q4H, PRN, see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
		650 mg, Suppository, RECTALLY, Q6H, PRN, see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
	ibuprofen
		600 mg, Tab, By Mouth, Q6H, PRN, pain-mild
			Comment: pain rating 1-3
		800 mg, Tab, By Mouth, Q8H, PRN, pain-mild
			Comment: pain rating 1-3
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-mild
			Comment: pain rating 1-3
	Percocet 5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-mild
			Comment: pain rating 1-3
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q2H, PRN, pain-mild
			Comment: for pain rating 1-3 and if NPO
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN, pain-mild
			Comment: for pain rating 1-3 and if NPO
Moderate Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-10 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Percocet 5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Percocet 7.5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Percocet 10 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Roxicodone
		5 mg, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	morphine  oral immediate release
		15 mg, Tab, By Mouth, Q4H, PRN, pain-moderate
			Comment: Pain rating 4-6
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q2H, PRN, pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		0.4 mg, Injection, IV Push, Q2H, PRN, pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN, pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		4 mg, Syringe, IV Push, Q2H, PRN, pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	ketorolac injectable
		15 mg, Injection, IV Push, Q6H, PRN, pain-moderate, 48 hr
			Comment: For pain rating 4-6.
Severe Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 5 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 7.5 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Percocet 10 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Roxicodone
		10 mg, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	morphine  oral immediate release
		30 mg, Tab, By Mouth, Q4H, PRN, pain-severe
			Comment: Pain rating 7-10
	Dilaudid Injectable
		0.4 mg, Injection, IV Push, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics. Use 0.4mg if over age 70.
		0.5 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics. Use 0.4mg if over age 70.
		0.6 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO
		0.8 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO
		1 mg, Injection, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10 if NPO
	morphine  IV
		4 mg, Syringe, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
		6 mg, Syringe, IV Push, Q2H, PRN, pain-severe
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
		Opiate Reversal(NOTE)*
	Narcan
		0.2 mg, Injection, IV Push, Q2MIN, PRN for see comment
			Comment: if patient has received opiate agents in the past 24 hours and/or if patient becomes somnolent with minimal or no response to stimuli or respiratory rate is 10 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone.  May give 0.2mg every 2 min up to 1mg total dose.
Constipation
	docusate
		100 mg, Capsule, By Mouth, DAILY
			Comment: Hold for diarrhea
	Senokot S 50 mg-8.6 mg oral tablet
		2 TAB, Tab, By Mouth, QHS
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, Q12H, PRN, constipation
			Comment: Mix in 6 oz juice or water
		17 gm, Packet, By Mouth, DAILY, PRN, constipation
			Comment: Mix in 6 oz juice or water
	Milk of Magnesia 8% oral suspension
		30 mL, Suspension, By Mouth, DAILY, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
		30 mL, Suspension, By Mouth, Q12H, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
	Dulcolax
		10 mg, Suppository, RECTALLY, DAILY, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
		10 mg, Suppository, RECTALLY, Q12H, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN, constipation
			Comment: If bisacodyl ineffective
	Enema-Administer
		Tap water, Q1H, constipation
			Comment: if suppository ineffective
Nausea Vomiting
	ondansetron
		4 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		Select either promethazine or prochlorperazine orders(NOTE)*
	prochlorperazine
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures, give if IV access not available.
	Phenergan (MH/WH)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		6.25 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (FH)
		12.5 mg, INT, IVPB, Once, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		25 mg, INT, IVPB, Once, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (JE)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Reglan
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
		10 mg, Injection, IM-Intramuscular, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
Patient Care

	Notify MD
		If patient develops itching
		if no results from enema.

Pain Constipation Nausea Protocol > 65 Geriatric E
Medications
		Select only one medication in each category(NOTE)*
Mild Pain
	acetaminophen
		1,000 mg, Tab, By Mouth, Q8H-Sch, T;N
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
		1,000 mg, Tab, By Mouth, Q8H, PRN pain-mild
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
		1,000 mg, Tab, By Mouth, Q8H-Sch, T+1;N
			Comment: For pain rating 1-3; Consider IV Acetaminophen (Ofirmev) if NPO.
	acetaminophen 10 mg/mL intravenous solution
		1,000 mg, Solution-Injection, IVPB, Q8H, T;N, duration: 3 Dose(s)/Time(s)
			Comment: For pain rating 1-3.
Moderate Pain
	oxyCODONE
		2.5 mg, Tab, By Mouth, Q4H, PRN pain-moderate
			Comment: For pain rating 4-6
	traMADol
		25 mg, Tab, By Mouth, Q6H, PRN pain-moderate
			Comment: For pain rating 4-6; Screen for drug interactions (e.g.SSRI), and adjust dose for CrCl<30ml/min; avoid use if history of seizures.
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Q4H, PRN pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics.
Severe Pain
	oxyCODONE
		5 mg, Tab, By Mouth, Q4H, PRN pain-severe
			Comment: For pain rating 7-10.
	traMADol
		50 mg, Tab, By Mouth, Q6H, PRN pain-severe
			Comment: For pain rating 7-10; screen for drug interactions (e.g.SSRI), and adjust dose for CrCl<30ml/min; avoid use if history of seizures.
	Dilaudid Injectable
		0.4 mg, Injection, IV Push, Q2H, PRN pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics.
		Opiate Reversal(NOTE)*
	Narcan
		0.2 mg, Injection, IV Push, Q2MIN, PRN see comment
			Comment: If patient has received opiate agents in the past 24 hours and/or if patient becomes somnolent with minimal or no response to stimuli or respiratory rate is 10 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone.  May give 0.2mg every 2 min up to 1mg total dose.
PRN Discomfort
	trolamine salicylate 10% topical cream
		1 appl, Cream, TOPICAL, TID, PRN discomfort
			Comment: Apply to affected area.
	menthol-methyl salicylate topical
		1 appl, Cream, TOPICAL, TID, PRN discomfort
			Comment: Apply to affected area.
	lidocaine 4% topical patch
		1 patch, Patch, TransDERMAL, DAILY
	lidocaine Patch Removal
		Patch Removal, Patch, TransDERMAL, QHS
	Medication patch site check
		T;N+720, Q12H
Constipation
	Senokot S 50 mg-8.6 mg oral tablet
		1 TAB, Tab, By Mouth, BID, PRN for constipation
			Comment: Hold for loose stools
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, BID
			Comment: Hold for loose stools.  Mix in 6oz juice or water.
	Dulcolax
		10 mg, Suppository, RECTALLY, Q12H, PRN constipation
			Comment: If other agents ineffective or if patient NPO.
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN constipation
			Comment: If suppository ineffective.
	Enema-Administer
		Tap water, Q1H, see comment
			Comment: If suppository ineffective.
Nausea Vomiting
	ondansetron
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN nausea and/or vomiting
		4 mg, Injection, IV Push, Q6H, PRN nausea and/or vomiting
			Comment: If unable to take by mouth.

Stroke Mechanical Thrombectomy Femoral Approach (M
Activity

	Bedrest
		T;N, 6, hr
			Comment: 6 hours post sheath removal
	Elevate head of bed
		T;N
			Comment: Continuously                                                                                                                                                       May elevate head of bed maximum 30 degrees
	Activity-As Tolerated
		After bedrest completed
	Activity-Restrictions
		T;N, No lifting > 10 pounds for 48 hours
	Limb Alert
		Immobilize affected limb while on bedrest
Patient Care
	Vascular Assessment-Focused
		T;N
			Comment: Now then every15 minutes x 4, every 30 minutes x 2, 1 hour x 4Assess for (CMS) circulation (including Doppler pulses), movement, and sensation of bilateral extremities
	Incision/Drain Assessment-Focused
		T;N
			Comment: Now then every15 minutes x 4, every 30 minutes x 2, 1 hour x 4. If bleeding or hematoma occurs at the femoral site, apply manual pressure, restart bedrest, and notify Provider
	Notify MD
		bleeding or hematoma, loss of distal pulses or extremity ischemia
	Incision/Dressing Care
		T;N
			Comment: Okay to remove transparent dressing (from access site) in 24 hours.

Stroke Mechanical Thrombectomy Radial Approach (MH
Activity
	Bedrest
		T;N, 6, hr
			Comment: 6 hours post radial device removal
	Activity-As Tolerated
		After bedrest completed
	Activity-Restrictions
		T;N
			Comment: Do not lift more than 10 pounds for 5 days after radial device removal. No push or pulling with affected arm for 24 hours.
	Elevate head of bed
		T;N, Elevate head of bed 30 degrees
			Comment: Continuously
Patient Care
	Vascular Assessment-Focused
		T;N
			Comment: Now then every15 minutes x 4, every 30 minutes x 2, 1 hour x 4Incision/drain assessment and vascular assessment with each vital signs check. Assess for (CMS) circulation (including Doppler pulses), movement, and sensation of bilateral extremities distal to the site of puncture
	Incision/Drain Assessment-Focused
		T;N
			Comment: Now then every15 minutes x 4, every 30 minutes x 2, 1 hour x 4. If bleeding or hematoma occurs at the site, apply manual pressure, restart bedrest, and notify Provider
	Notify MD
		of bleeding or hematoma, loss of distal pulses or extremity ischemia
	No Venipunctures
		Or blood pressures on affected limb for 24 hours post procedure
	Hemostatic Compression Device
		T;N
			Comment: Start deflation of radial band 2 hours after radial band applied. Remove 3ml of air every 10 minutes until air is removed. If bleeding occurs when 2ml is removed, re-inflate with 2 ml of air. Wait 20 minutes then restart deflation. If site is free of complications after 1 hour, remove radial again and apply transparent dressing. Keep compression device at bedside in case of bleeding complications.

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase