Stroke Discharge Orders (check box v to activate orders) by gph1reD0

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Stroke Discharge Orders                         (check box √ to activate orders)
                                                                                             PT NAME

                                                                                             BIRTHDATE
STROKE DISCHARGE DIAGNOSIS: ____________                  Primary         Secondary
                                                                                             LOCATION                    DATE
ALLERGIES: ______________ _______________ _______________ ______________

ANTITHROMBOTIC MEDICATION:
Name                                                 Dosage                                Route/Frequency
  Aspirin                                            81 or 325 mg Tab                      PO daily
  Aggrenox                                           1Tab                                  PO BID
  Clopidogrel                                        75 mg                                 PO daily
  Coumadin                                                                                 PO daily at bedtime
  Other
  No antithrombotics - Reasons for Non-Treatment:
           Allergy or prior adverse reaction to Rx                                            Peptic ulcer (current)
           Bleeding disorder                                                                  Terminal/comfort care or terminal illness
           Risk of bleeding (current)                                                         CVA Hemorrhagic (hx or current)
           Other:

ANTIHYPERTENSIVE MEDICATION:
                                           Name                                   Dosage                              Route/Frequency
    ACE Inhibitor
    ARB
    Thiazide Diuretic
    Other medication(s)



    No antihypertensive – Reasons for Non-Treatment:
                     Low blood pressure (<130/80)                         Increased symptoms with lower pressure
                     Orthostatic hypotension                              Other: _______________________________

LIPID LOWERING MEDICATION:
                                               Name                               Dosage                              Route/Frequency
    Statin
    Other medication(s)
    No lipid lowering medication – Reasons for Non-Treatment:
              LDL <100                                                    Hepatitis/liver failure
              Allergy or prior adverse reaction to Rx                     Other: _______________________________

RISK FACTOR MODIFICATION EDUCATION:
Exercise                     Counseling                         Your Health Matters/Information Sheet
Diet                         Counseling                         Your Health Matters/Information Sheet
Smoking Cessation            Counseling                         Your Health Matters/Information Sheet                    Non-Smoker
Stroke warning signs         Counseling                         Your Health Matters/Information Sheet

FOLLOW UP:
 LABS - (provide lab slip for draw 6 weeks post discharge)     Potassium and creatinine          ALT, LDH, ALK-P’tase, Total Bilirubin
   Stroke Clinic Appointment                                   Patient to call                         Scheduled:
                                                                                                        Date:___/___/___
                                                                                                        Time:___/___/___
   PMD Appointment                                             Patient to call                         Scheduled:
                                                                                                        Date:___/___/___
                                                                                                        Time:___/___/___

FLAG CHART       Signature _______________________ M.D.                 Beeper# ______________ M.D. # ___ ___ ___ ___ ___
TO INDICATE      Print Name ______________________ M.D.
NEW ORDER        Checked by ______________________ R.N.                 Time _________________ Date ___________________

								
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