Name

Age

Date of Birth

Medical record

Status

Name of attending physician

Phone number of attending physician

CVA Associated Diagnoses

Condition

Code Status

NPO

Clear liquid

AHA step 2

ADA___calories

If diet according to ADA, please specify amount of calories

Other

If Other, please specify

Activity

Vital signs with neuro checks every 4hrs for 24 hrs then per routine

Notify MD for: BP systolic < 90 or > 180 or > 105 diastolic; P < 60 or > 120; declining mental status or worsening of neurological symptoms

Weigth on arrival

I&O every shift

O2 @ 2,4,6 L/min via NC or FM

Check pulse ox on arrival and pen to maintain O2 sat > 92%

ASA 81 mg PO daily

Folate 1 mg PO daily

Dextrose 5% in 1/2 normal saline with 20 mEq KCl/L at 80 mL/hr

Hep lock

Other

If other, please specify

Admission: CBC, PT/INR, comp med profile, cardiac profile

a.m.: lipid profile, TSH

CT Head without contrast (if not done in ER)

ECG (if not done in ER)

Portable CXR (if not done in ER)

Echocardiogram - to be read by__

If Echocardiogram, please specify: to be read by___

If Other, please specify

If Other, please specify

PT evaluation

OT evaluation

Speech/swallow evaluation

Signature

Print Name

Date and Time