ValleyProtocolBook

The Valley Hospital MICU Department Standards of Care

Neurological Assessment: CVA/TIA: 1. Assess LOC for presence of stupor, delirium, hallucinations 2. Full set of ALS vitals (BP, pulse, respirations) 3. Obtain a blood sugar reading 4. Obtain 12 lead ECG 5. Assess for presence of unsteady gait 6. Pupillary response 7. Neurological exam (speech, motor, vision, dysphasia, numbness, tingling, swallowing, vertigo) 8. Assess if the patient has a headache 9. Ascertain the past medical history, medications, allergies

Seizure:

1. Assess LOC 2. Full set of ALS vitals (BP, pulse, respirations) 3. Obtain 12 lead ECG for adult patient with prior cardiac and/or arrhythmia history 4. Obtain a blood sugar reading 5. Assess if the patient has a headache and/or nausea and vomiting

6. Pupillary response 7. Neurological exam 8. Assess for tongue trauma and/or incontinence 9. Assess for fever 10. Ascertain duration and type of seizure 11. Ascertain the past medical history, medications, allergies