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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

Source: http://vhhdoctor.org/documents/Stroke/Intracerebral%20Hemorrhage%20Admitting%20Orders%207-2012.pdf