stroke clinical pathway checklist acute - medical€¦ · initials date time-> alert 3.0 drowsy...

1.

2.

3.

4.

5.

� Discharge Criteria - original to stay on patient chart� MAR Sheet - original to stay on patient chart

� Anticoagulant Record - original to stay on patient chart

� Teaching Checklist - original to stay on patient chart� Caregiver Checklist - original to stay on patient chart

GREY BRUCE HEALTH NETWORK

All Stroke patients over 18 years of age admitted to hospital.

HOW TO USE THE CLINICAL PATHWAY

This is a proactive tool to avoid delays in treatment and discharge.

These are not orders, only a guide to usual order.

TRANSFER PATIENTS: If patient is transferred to another hospital in Grey-

Bruce or to CCAC, send a copy of the following:

STROKE

ACUTE - MEDICAL

CLINICAL PATHWAY CHECKLIST

PATIENT ID

INCLUSION CRITERIA:

HEALTH CARE PROFESSIONALS: Place appropriate symbol in space

provided: ie done not done or symbol provided and relevant.

Place N/A in any box where the task is not applicable to the patient.

Additional tasks due to patient individuality can be added to the pathway in

“OTHER” boxes and/or Progress Notes. NOT ALL TASKS WILL APPLY TO

EVERY PATIENT.

MULTIDISCIPLINARY TEAMS: Sign and date appropriate sheet on first

contact with patient and each day the patient is seen.

Place the Clinical Pathway in the nurses clinical area of the chart. All health

care professionals should fill in the master signature sheet at the front of the

Pathway. Addressograph/sticker each page of the Pathway.

Updated Jan 2011© 2004-2011 Grey Bruce Health Network

1Review Jan 2013

NAME

(Please Print)INITIAL SIGNATURE

DESIGNATION

(RN / RPN/ OTHER)

All rights reserved. No part of this document may be reproduced or transmitted, in any form

or by any means, without the prior permission of the copyright owner.

Updated Jan 2011© 2004-2011 Grey Bruce Health Network

2Review Jan 2013

PAIN ASSESSMENT: SCORE 0 - 10

URINE COLOUR:CATHETER TYPE AND SIZE:

ASSESSMENT

(OBSERVATIONS/

MEASUREMENTS/

ELIMINATION)

TREAT TEMPS >37.5 *NOTIFY PHYSICIAN FOR TEMP > 38.5

ECG

LABORATORY /

DIAGNOSTICSCT SCAN

OTHER:

BLOOD WORK (Specifically CBC, APTT, INR, ELECTROLYTES,

CREATININE, GLUCOSE)

CONTINUOUS CARDIAC MONITOR /

RHYTHM STRIPS INTERPRETTED AND ATTACHED

* DOES PATIENT HAVE KNOWLEDGE / DOCUMENTED HISTORY OF

HAVING AN IRREGULAR HEART RATE / PREVIOUS STROKE?

* RELEVENT / EMERGENT COMORBIDITIES DOCUMENTED

OTHER:

ER ADMISSION SIGNATURE:

ER TRANSFER SIGNATURE:


INITIAL ASSESSMENT CANADIAN NEUROLOGIC SCALE, then Q1H &

PRN - STROKE ASSESSMENT SYSTEM SCORE SHOULD NOT

DECREASE MORE THAN ONE (1) (Indicate Score)

STROKE

*NOTIFY PHYSICIAN IF SBP > 220 OR DBP > 120 FOR 2 OR MORE

READINGS 5-10 MIN APART

OTHER:

CLINICAL PATHWAY CHECHLIST

INITIAL VITAL SIGNS + O2 SATS

�� = Done �� = Not Done N/A = Not Applicable

* requires descriptive charting in progress notes

EMERGENCY PHASE

0 - 3 HOURS

MONITOR FLUID INTAKE AND OUTPUT:

V - Voided C - Catheter I - Incontinent

PATIENT ID

PROCESS

**Immediate Notification of the Acute Stroke Multidisciplinary Team is recommended on admission**

THOSE PATIENTS STAYING LONGER THAN 3 HOURS IN ER WILL HAVE ACUTE PHASE ACTIVATED

ACUTE - MEDICAL

DATE / TIME

__________

DATE / TIME

__________

ER PHASEON

TRANSFER

CHEST ASSESSMENT: C - Clear *A - Adverse sounds

Updated Jan 2011© 2004-2011 Grey Bruce Health Network 3

Review Jan 2013

`

ADVANCE DIRECTIVE DISCUSSION ADDRESSED

CONSULTS

TRANSFER

STROKE

PSYCHOSOCIAL

SUPPORT/

EDUCATION

PATIENT / FAMILY INFORMED OF DIAGNOSIS / REASON FOR

ADMISSION

ADDRESS IMMEDIATE CONCERNS

NUTRITIONNPO

OTHER:

MOBILITY/ACTIVITYBED REST

OTHER:

TREATMENTS/

INTERVENTIONS

IV SITE ESTABLISHED / INSITU AND SATISFACTORY

2ND IV SITE ESTABLISHED / INSITU AND SATISFACTORY

OTHER:


ACUTE - MEDICAL PATIENT ID

PROCESS

EMERGENCY PHASE

0 - 3 HOURS �� = Done �� = Not Done N/A = Not Applicable



ER PHASEON

TRANSFER

DATE / TIME

__________

DATE / TIME

__________

OTHER:

MEDICATIONS

ISCHEMIC NON-THROMBOLYTIC / NON-HEMMORAGIC STROKE ONLY:

ASA 160 mg PO @ ___________________

BEST MEDICATION RECONCILIATION FORM COMPLETED AND SIGNED

ISCHEMIC STROKE THROMBOLYTIC THERAPY ONLY:

ALTEPLASE (tPA) @ _____________________

OTHER:

ACETAMINOPHEN FOR TEMPERATURE > 37.5

ER ADMISSION SIGNATURE:

ER TRANSFER SIGNATURE:

CONFIRM ORDER FOR ACUTE STROKE MULTIDISCIPLINARY TEAM

ENTERED IN CERNER AS:

C - Confirmed stroke OR U - Unconfirmed stroke

REPORT CALLED TO RECEIVING UNIT INDICATED TIME: __________

INFECTION CONTROL SCREENING QUESTIONS REVIEWED FOR

APPROPRIATE BED PLACEMENT


Review Jan 2013

Initials

Date Time->

Alert 3.0

Drowsy 1.5

Orientation Oriented 1.0

Mentation Disoriented or N/A 0.0

Speech Go to A¹ Normal 1.0

Go to A¹ Expressive deficit 0.5

Go to A² Receptive deficit 0.0

A¹ Face Symmetrical 0.5

Asymmetrical 0.0

Arm: Proximal None 1.5

No Mild 1.0

Commu- Significant 0.5

nication Total 0.0

Deficit Arm: Distal None 1.5

Mild 1.0

Significant 0.5

Total 0.0

Leg: Proximal None 1.5

Mild 1.0

Significant 0.5

Total 0.0

Leg: Distal None 1.5

Mild 1.0

Significant 0.5

Total 0.0

Motor Repsonse:

A² Face Symmetrical 0.5

0 Asymmetrical 0.0

Compre- Arms Equal 1.5

hension Unequal 0.0

Deficit Legs Equal 1.5

Unequal 0.0

Total Score

+ = reacts Right Size

Pupil - = no reaction Reaction

Reaction Sl = sluggish Left Size

C = closed Reaction

Pupil Size:

Heart Rate

Vital Blood Pressure

Signs Temperature

Respiration

0² Saturation

Initials->

Signature/Status

CANADIAN NEUROLOGICAL SCALE - STROKE ASSESSMENT SYSTEM

Level of conciousness

Motor Functions:

� 1mm � 2mm � 3mm � 4mm � 5mm � 6mm

Updated Jan 2011 © 2004-2011 Grey Bruce Health Network5

Review Jan 2013

Date Time->

Initials->

GRAPH TOTAL SCORE OF CANADIAN NEUROLOGIC SCALE

STROKE ASSESSMENT SYSTEM

** Plot total points from calculated score directly on the vertical line that corresponds with the total score for each

time tested. Draw a line to connect all points. This allows for early recognition of deterioration or improvement in

patient's condition.

11.511

10.510

9.59

8.58

7.57

6.56

5.55

4.54

3.53

2.52

1.5


Review Jan 2013

(A) Face -

(B) Arm -

(B) Arm -

Section: A1 Weakness - No Comprehension Deficit (Expressive Deficit)

NOTE: When evaluating strength and range of motion in limbs, submit both limbs to same testing. "R"

or "L" identifies side with weakness. Only mark for the side with the greatest deficit or variation.

None: Ask the patient to show their teeth and grin. Is it symmetrical (even)?

Present: Ask the patient to show their teeth and grin. Is it asymmetrical (uneven)?

Proximal: (Test in sitting position if possible.) Apply resistance at midpoint between

shoulder and elbow, and ask patient to elevate arms to 45 - 90 degrees. Monitor for

weakness.

Distal: (Test in sitting or lying position.) Patient makes fists and elevates arms, with

extended wrists. Check for full range of motion in both wrists, then proceed to apply

resistance separately to both fists while stabilizing the patient's arm firmly.

iii) Receptive - Ask patient to follow three commands: Close your eyes, point to the ceiling, and wiggle

toes. (Do not mimic commands.) If patient follows all three, then proceed to expressive deficit testing. If

unable to obey all 3 commands, score receptive deficit and proceed to section A2.

i) Alert - Normal Consciousness

ii) Drowsy - Wakens when stimulated verbally but tends to doze off to sleep.

(B) Orientation

i) Oriented - To both place and time. Example: hospital or city plus month and year. If it is within first

few days of a new month, the previous month is acceptable. Speech can be mispronounced or slurred,

but intelligible.

ii) Disoriented or Non Applicable - If patient can not answer place and time questions. Example: doesn't

know the answer, partial answer or cannot express answer in words or intelligible speech.

(C) Speech - Testing for speech deficits.

i) Normal - Answers all questions and commands. Can be slurred but intelligible. Proceed to A1.

ii) Expressive - Show patient 3 objects: pencil, key and watch. Ask the patient to name all 3 objects. If

patient makes one or more errors and/or mispronounces words (slurred speech) or patient names all

three objects, ask the patient "what do you do with a key? ... a watch? ... and a pencil? If the patient

answers all three, then they are normal speech. If they answer only 2 or less, then they are expressive

speech.

(A) Level of Consciousness

Effective Use of the Stroke Assessment System (SAS)

SAS is only used for the stroke patient who is either alert or drowsy.

NOTE: Use the Glasgow Coma Scale for patients who are Stuporous (responds to loud stimuli

but does not become alert) or Comatose (responds to deep pain only).

Section: Mentation


Review Jan 2013

Proximal:

Distal:

Grading level of Weakness

i) None - No detectable weakness.

ii)

iii)

iv)

(A) Face - Symmetrical: Ask the patient to show their teeth and grin. Is it symmetrical (even)?

(B) Arm

(C) Legs

Grading Level of Motor Response:

i) Equal

ii) Unequal

- Flex thighs with knees flexed at 90 degrees, one limb at a time. Note ability to maintain a

fixed posture for 3-5 seconds.

If patient is unable to cooperate, compare motor response to a noxious stimulus (e.g. pressure on

fingernail, toenail). Facial response (grimacing) to pain is tested by applying pressure to the sternum.

- Patient can maintain the fixed posture equally in both limbs for a few seconds or

withdraws equally on both sides to pain.

- Patient cannot maintain fixed position equally on either side or unequal withdrawal to

pain. Note side.

Mild - Normal range of motion against gravity but succumbs to

resistance wither partially or totally.

Significant - Cannot completely overcome gravity in range of motion

(only partial movement).

Total - Absence of motion or only muscle contrition without

movement.

Section: A2 Motor Response - Comprehension Defect (Receptive Deficit)

- Asymmetrical: Ask the patient to show their teeth and grin. Is it asymmetrical (uneven)?

Note side.

- Place the arms outstretched at 90 degrees - one limb at a time. Note ability to maintain a

fixed posture for 3-5 seconds.

ii) Dorsi Flexion of foot. Have patient point toes and foot upwards. Apply resistance to one foot at a

time, to test for weakness.

Section: A1 Weakness - (Continued)

(C) Leg: (Test patient lying in bed)

i) Hip Flexion - Have patient flex thighs toward trunk with knees flexed at 90 degrees. Apply

resistance, one thigh at a time, to test for weakness.


Review Jan 2013

INITIALS:

CATHETER

REMOVED:

INITIALS:

DYSPHAGIA SCREENING TOOL

COMPLETED (Once Q24H) 1

URINE COLOUR:

PAIN ASSESSMENT Q4H: * I - Intervention

SCORE 0 - 10

INTAKE AND OUTPUT QSHIFT (Nofity physician for < ________ mL/h)

V - Voided C - Catheter I - Incontinent HNV - Has Not Voided

CANADIAN NEUROLOGIC SCALE:

Day 1: Q_____H; Day 2: Q____H; Day 3: Q____H, then daily SCORE

SHOULD NOT DECREASE BY MORE THAN ONE (1) (Indicate Score)

OTHER:

BOWEL ROUTINE: C - Continent I - Involuntary O - Ostomy




STROKE

Pass / Fail keep NPO

RECORD REGULARITY OF HEART RATE (Note if patient aware of any

past anomalies) REG - Regular / IRREG - Irregular

(Record QSHIFT on Checklist)

ACUTE CARE PHASE

PROCESSDATE: DATE:

DAY 1 DAY 2 DAY 3

DATE:



PERFORMANCE

INDICATORS

� Met � Not Met � N/A

ASSESSMENT

(OBSERVATIONS/

MEASUREMENTS/

ELIMINATION)

VITAL SIGNS + O2 SATS:

(Thrombolytic increased frequency as ordered)

(Non-Thrombolytic - Day 1: Q4H Day 2: QID Day 3: QSHIFT

* NOTIFY PHYSICIAN IF SBP > 220 OR DBP > 120 FOR 2 OR MORE

READINGS 5-10 MIN APART X 48 HOURS

TREAT TEMPS >37.5 * NOTIFY PHYSICIAN FOR TEMP > 38.5

CHEST ASSESSMENT Q4H: C - Clear * A - Adverse sounds

RESTRAINT OBSERVATION Q _______ MIN

* CONSENT OBTAINED FOR MINIMAL RESTRAINT FOR SAFETY AND

REASSESSED Q24H

MODIFIED RANKIN SCALE (Indicate Score)

BRADEN (SKIN) RISK ASSESSMENT COMPLETED

ON ADMISSION AND PRN (Indicate Score)

PATIENT SAFETY

CUES

OTHER:

MORSE FALL RISK ASSESSMENT COMPLETED

ON ADMISSION AND PRN (Indicate Score)

* MORSE FALL RISK INTERVENTIONS DOCUMENTED

PATIENT SAFETY CUE CARDS IN PLACE IN ROOM

(no straws, acute stroke checklist, fall risk symbol, etc)


Review Jan 2013

NUTRITION

OTHER:

ALTERNATE ROUTES DETERMINED FOR MEDS IF PATIENT NPO

PROCESS

ACUTE CARE PHASE

MOBILITY /

ACTIVITY

INITIALS:

NON-THROMBOLYTIC - ACTIVITY AS TOLERATED

THROMBOLYTIC - RESTRICTED AS ORDERED X 24 HOURS

SPECIAL EQUIPMENT:

SLEEP: R - Restless F - Fair W - Well

PERSONAL HYGIENE:

C - Complete / Cueing required A - Assist S - Self

OTHER:

* USE POSITIONING TO MAINTAIN PROPER BODY ALIGNMENT (SEE

"TIPS AND TOOLS" BOOK FOR REFERENCE PURPOSES)

DIET TEXTURE AS PER DYSPHAGIA SCREENING TOOL:

____________________________ (Diet order from physician only)

HEAD OF BED ELEVATED MINIMUM 30 DEGREES FOR NPO / TUBE

FED PATIENTS

OTHER:

F - Feed self A - Assist C - Complete feed

(% of diet taken if not NPO)

OTHER:


STROKE



* ASSESS RISK / NEED FOR DVT PROPHYLAXIS WITH PHYSICIAN

(Limited Mobiltiy / type of stroke significant in rationale for ordering)

IV AND/OR INTERMITTENT SET OBSERVATION AND SITE CARE Q1H

S - Satisfactory C - Changed R - Removed



LABORATORY /

DIAGNOSTICS

BLOOD WORK AS ORDERED: (Documenting procedure completed)

SWABS MRSA & VRE COMPLETED ON ADMISSION THEN Q WEEKLY

DIAGNOSTICS:

MEDICATIONS

TREATMENTS/

INTERVENTIONSIF NON-AMBULATORY: S - anti-emboli Stockings

or C - sequential Compression device

(Record Q4H on Checklist) DATE: DATE: DATE:

DAY 1 DAY 2 DAY 3

NG FEEDING ESTABLISHED / CLINICAL NUTRITION CONSULT

PROTOCOL INITIATED / ENTER FEEDING ORDER SET INITIATED


Review Jan 2013

DISCHARGE

PLANNING

Progress Notes:


STROKE

ACUTE CARE PHASE

(Record Q4H on Checklist)



* ADDRESS PATIENT AND FAMILY ANXIETY IF APPLICABLE /

* ENCOURAGE PATIENT AND FAMILY TO ASK QUESTIONS

PSYCHOSOCIAL

SUPPORT/

EDUCATION

* BARRIERS TO LEARNING DOCUMENTED (Patient or Family)

*SPECIFIC COMMUNICATIN / NEGLECT DEFICITS DOCUMENTED

GIVE PATIENT PATHWAY TO PATIENT / FAMILY

BEGIN / CONINUE TEACHING CHECKLIST WHEN APPROPRIATE

(Patient/family have received "LET'S TALK ABOUT STROKE" book)

ASSESS DISCHARGE CRITERIA DAILY

- Assess readiness for rehabilitation using referral form

- Complete Blaylock Discharge Planning Risk Assessment Screen

- Fax referral to Community Stroke Team when discharged

INITIALS:

DAY 1 DAY 2 DAY 3



PROCESSDATE: DATE: DATE:


Review Jan 2013

Progress Notes:

* CLINICAL NUTRITION

* PHARMACIST

* OTHER:

* CCAC / DISCHARGE PLANNING

* SOCIAL WORKER


STROKE



��DATE &

TIMESIGNATURE

CONSULTS(To be completed by

individual discipline

and signed with signature)

ACUTE CARE PHASE

MULTIDISCIPLINARY TEAM

�� = Individual Disciplines have reviewed and

updates recorded accordingly

UPDATE PATIENT STROKE STATUS IN CERNER AS CONFIRMED OR

UNCONFIRMED TO ACTIVATE THE ACUTE STROKE MULTIDICIPLINARY

TEAM

* PHYSIOTHERAPY

* OCCUPATIONAL THERAPY

* SPEECH/LANGUAGE PATHOLOGIST IF REQUIRED


Review Jan 2013

� Patient � Family member

� Patient’s physician � Registered Nurse

� Other: Specify

DESCRIPTION QUESTIONS TO CONSIDER FOR GRADING

Baseline Discharge

� 0 � 0 No symptoms at all. No limitations.

� 1 � 1

No significant disability

despite symptoms; able to

carry out all usual duties and

activities.

Does person have difficulty reading or writing,

speaking, problems with balance/coordination,

visual problems, numbness, loss of movement,

difficulty swallowing or other symptoms resulting

from stroke?

� 2 � 2

Slight disability; unable to

carry out all previous

activities but able to look

after own affairs without

assistance.

Has there been a change in person’s ability to work

or look after others if these were roles before

stroke? Change in person’s ability to participate in

previous social and leisure activities? Problems

with relationships or become isolated?

� 3 � 3

Moderate disability; requiring

some help, but able to walk

without assistance.

Is assistance essential for preparing a simple meal,

doing household chores, looking after money,

shopping or traveling locally?

� 4 � 4

Moderately severe disability;

unable to walk without

assistance, and unable to

attend to own bodily needs

without assistance.

Is assistance essential for eating, using the toilet,

daily hygiene, or walking?

� 5 � 5

Severe disability; bedridden,

incontinent, and requiring

constant nursing care and

attention.

Requires constant care.

RN / MD Signature: /Baseline assessment Discharge assessment

Please indicate who provided the information:

GRADE

� Admission date: __________________________________________

MODIFIED RANKIN SCALE

� Discharge from Acute Care date: _____________________________

* This is to be completed on all Stroke as baseline (pre-treatment) and discharge from Acute Care*

Updated May 2011 © 2004-2011 Grey Bruce Health Network13

Review Jan 2013

DATE_______

DATE_______

DATE_______

RISK FACTOR 1 2 3 4

Sensory Perception: Ability

to respond meaningfully to

pressure—related discomfort

Completely

LimitedVery Limited

Slightly

Limited

No

Impairment

Moisture: Degree to which

skin is exposed to moisture

Constantly

MoistOften Moist

Occasionally

Moist

Rarely

Moist

Activity: Degree of Physical

ActivityBedfast Chair Fast

Walks

Occasionally

Walks

Frequently

Mobility: Ability to change

and control body position

Completely

ImmobileVery Limited

Slightly

Limited

No

Limitations

Nutrition: Usual food intake

patternVery Poor

Probably

InadequateAdequate Excellent

Friction and Sheer ProblemPotential

Problem

No Apparent

Problem

LOW RISK

(SCORE > 15)

Ongoing assessment for

change in status related to

any of the six risk areas

Document reassessment

weekly on Kardex

-Physiotherapy

-Continence management -Occupational Therapy

-Activity level (i.e. turning, positioning)

-Monitoring of pressure point areas -Dietitian

SCORING (Key on Reverse)

SCORE

TOTAL SCORE

PATIENT ID

-Patient education re: prevention

-Monitor nutritional status

-Skin care tools used: prevention

mattresses or treatment (i.e. air

mattresses), creams, bed hoop, trapeze,

dressings

Initiate and document plan of care on

Kardex and Unit specific Progress

Notes including:

Includes “Moderate Risk Intervention” plus

requested referral to:

NURSE’S INITIALS

Nursing Intervention: Once you have assessed the patient and identified a risk category (high, moderate or low), carry

out the following interventions for the patient's risk category.

MODERATE RISK

(SCORE 13-14)

HIGH RISK

(SCORE < 12)


CLINICAL PATHWAY

ACUTE - MEDICAL

Braden Risk Assessment

STROKE


Review Jan 2013

Braden Risk Assessment - page 2

RISK FACTOR

Moisture

Degree to which skin is

exposed to moisture

1. Constantly Moist

Skin is kept moist almost

constantly by perspiration,

urine, etc. Dampness is

detected every time patient is

moved or turned.

2. Often Moist

Skin is often, but not

always moist. Linen must be

changed at least once a shift.

3. Occasionally Moist

Skin is occasionally moist,

requiring an extra linen

change approximately once a

day.

4. Rarely Moist

Skin is usually dry, linen only

requires changing at routine

intervals.

Activity

Degree of physical

activity

1. Bedfast

Confined to a bed.

2. Chair Fast

Ability to walk severely

limited or nonexistent.

Cannot bear own weight

and/or must be assisted into

chair or wheelchair.

3. Walks Occasionally

Walks occasionally

during day, but for very short

distances, with or without

assistance. Spends majority

of each shift in bed or chair.

4. Walks Frequently

Walks outside the room at

least twice a day and

inside room at least once

every two hours during

waking hours.

Mobility

Ability to change and

control body position

1. Completely Immobile

Does not make even slight

changes in body or

extremity position without

assistance.

2. Very Limited

Makes occasional slight

changes in body or

extremity position, but

unable to make frequent or

significant changes

independently.

3. Slightly Limited

Makes frequent, though

slight changes in body or

extremity position

independently.

4. No Limitations

Makes major and frequent

changes in position

without assistance.

Nutrition 1. Very Poor

Never eats a complete meal.

Rarely eats more than 1/3 of

any food offered. Eats 2

servings or less of protein

(meat or dairy products) per

day. Takes fluids poorly.

Does not take a liquid dietary

supplement.

OR

Is on NPO and/or maintained

on clear fluids or IV for more

than 5 days.

2. Probably Inadequate

Rarely eats a complete meal

and generally eats only about

1/2 of any food offered.

Protein intake includes only 3

servings of meat or dairy

products per day.

Occasionally will take a

dietary supplement.

OR

Receives less than optimum

amount of liquid diet or tube

feeding.

3. Adequate

Eats over half of most meals.

Eats a total of 4 servings of

protein (meat, dairy products)

each day. Occasionally, will

refuse a meal, but will usually

take a supplement if offered.

OR

Is on a tube feeding or TPN

(Total Parenteral Nutrition)

regimen, which probably

meets most of nutritional

needs.

4. Excellent

Eats most of every meal.

Never refuses a meal.

Usually eats a total of 4 or

more servings of meat and

dairy products.

Occasionally eats

between meals. Does not

require supplementation.

Friction and Shear 1. Problem

Requires moderate to

maximum assistance in

moving. Complete lifting

without sliding against sheets

is impossible.

Frequently slides down in bed

or chair, requiring

frequent repositioning with

maximum assistance.

Spasticity, contractures or

agitation leads to almost

constant friction.

2. Potential Problem

Moves feebly or requires

minimum assistance.

During a move, skin probably

slides to some extent against

sheets, chair, restraints or

other devices. Maintains

relatively good position in

chair or bed most of the time,

but occasionally slides down.

3. No Apparent Problem

Moves in bed and in chair

independently and has

sufficient muscle strength to

lift up completely during

move. Maintains good

position in bed or chair at all

times.

SCORE/DESCRIPTION

Sensory Perception

Ability to respond

meaningfully

to pressure related

discomfort

1. Completely Limited

Unresponsive (does not

moan, flinch, or grasp) to

painful stimuli, due to

diminished level or

consciousness or sedation.

OR

Limited ability to feel pain

over most of body surface.

2. Very Limited

Responds only to painful

stimuli. Cannot

communicate discomfort

except by moaning or

restlessness.

OR

Has a sensory impairment,

which limits the ability to feel

pain or discomfort over 1/2 of

body.

3. Slightly Limited

Responds to verbal

commands but cannot always

communicate

discomfort or need to be

turned.

OR

Has some sensory

Impairment, which limits

ability to feel pain or

discomfort in 1 or 2

extremities.

4. No Impairment

Responds to verbal

commands. Has no

sensory deficit, which would

limit ability to feel or voice

pain or discomfort.


Review Jan 2013

INITIAL DATE

2

3

OTHER:

INITIALS:

ASSESSMENT

(OBSERVATIONS/

MEASUREMENTS/

ELIMINATION)

MODIFIED RANKIN SCALE IF PATIENT BEING DISCHARGED

FROM ACUTE CARE (Indicate Score)

BRADEN (SKIN) RISK ASSESSMENT UPDATED

DATE: DATE: DATE:

(Record Q4H on Checklist)

VITAL SIGNS QSHIFT & PRN INCLUDING 02 SATS

TREAT TEMPS >37.5 *NOTIFY PHYSICIAN FOR TEMP >38.5

SKIN INTEGRITY QSHIFT *N - Needs intervention

CANADIAN NEUROLOGICAL SCALE - STROKE ASSESSMENT

SYSTEM DAILY FOR 6 DAYS

REASSESS DYSPHAGIA SCREENING TOOL IF INDICATED

P - Pass F - Fail

MONITOR BOWEL AND BLADDER ROUTINE

C - Continent I - Incontinent

CHEST ASSESSMENT QSHIFT & PRN

C - Clear *A - Adverse sounds

PAIN ASSESSMENT QID & PRN *N - Needs intervention

Score 0 - 10



ACUTE - MEDICAL

STROKE

PATIENT ID

PERFORMANCE

INDICATORS

INTERDISCIPLINARY CONSULTS

COMPLETED� Met � Not Met � N/A

TRIAGE (TRANSITION PLAN)

COMPLETED

DAY:


* required descriptive charting in progress notes


PROCESS

TRANSITIONAL PHASE DAY: DAY:

PATIENT SAFETY

CUES

(UPDATED - PRN)

PATIENT SAFETY CUE CARDS IN PLACE IN ROOM

(no straws, acute stroke checklist, fall risk symbol)

MORSE FALL RISK ASSESSMENT *I - Interventions required

*CONSENT OBTAINED FOR MINIMAL RESTRAINT FOR SAFETY

AND REASSESSED Q24H

OTHER:

RESTRAINT OBSERVATION Q ______ MINUTES

LABORATORY /

DIAGNOSTICS

BLOOD WORK

DIAGNOSTICS

OTHER:


Review Jan 2013

INITIALS:

PSYCHOSOCIAL

SUPPORT/

EDUCATION

REVIEW PATIENT-SPECIFIC RISK FACTORS FOR

SECONDARY PREVENTION

ADDRESS QUESTIONS REGARDING PATIENT PATHWAY

AND/OR "LET'S TALK ABOUT STROKE" BOOKLET

ENGAGE FAMILY IN CAREGIVING

(Identify barriers and document for follow-up)

ADDRESS ANY QUESTIONS, FEARS AND ANXIETIES THE

PATIENT/FAMILY MAY HAVE

MEDICATIONS

TREATMENTS/

INTERVENTIONS

OTHER:

MOBILITY/ACTIVITY

CONTINUE METHOD OF PATIENT TRANSFER AND DOCUMENT

IN PATIENT CARE PLAN (SEE "HEALTHY MOVES" BOOKLET

FOR REFERENCE PURPOSES)

USE POSITIONING TO MAINTAIN PROPER BODY ALIGNMENT

(SEE "TIP AND TOOLS" BINDER FOR REFERENCE PURPOSES)

DOCUMENT TOLERATED SITTING TIME DAILY

REMIND PHYSICIAN OF REMOVAL OF URINARY CATHETER

REMOVAL DATE / TIME:

(Recommended after fluid balance established)

% OF DIET TAKEN IF NOT NPO

IF TUBE FEEDING T - Tolerated *A - Adjustments as ordered

DAY:

DATE: DATE:


PROCESS

DAY: DAY:

(Record Q4H on Checklist) DATE:

TRANSITIONAL PHASE




STROKE


� DIET TEXTURE AS PER DYSPHAGIA SCREENING TOOL

� REGULAR TEXTURE - HEALTHY HEART DIET

� SPECIAL DIET: ________________________

NUTRITION

OTHER:

IF NON-ABULATORY S - anti emboli Stockings

or C - sequential Compression device

BOWEL/BLADDER RETRAINING - PLAN DOCUMENTED AND

ONGOING *A - Adjustments made

ALL MEDICATIONS AND ROUTES ESTABLISHED

OTHER:

REASSESS IV WHEN ORAL INTAKE >1500 ML IN 24 HOURS

REMOVE/CHANGE IV SITE Q72H (INCLUDING TUBING)


Review Jan 2013

INITIALS:

Progress Notes:

REHABILITATION CONSULT DISCUSSION INITIATED

*BARRIERS TO REHABILITATION READINESS

- Plan commenced to optimize readiness / alternate plan

UPDATE AND REVIEW PLAN FOR DISCHARGE WITH

PATIENT/CAREGIVER

CAREGIVER TRAINING/EDUCATION CHECKLIST COMPLETED

AND UNDERSTOOD BY CAREGIVER

REFERRAL TO CCAC DISCHARGE PLANNING INITIATED

DATE / TIME:

DATE:


STROKE


TRANSITIONAL PHASE

DISCHARGE

PLANNING

ASSESS DISCHARGE CRITERIA DAILY AND NOTIFY

COMMUNITY STROKE TEAM WHEN PATIENT DISCHARGED



(Record Q4H on Checklist) DATE: DATE:


PROCESS

DAY: DAY: DAY:


Review Jan 2013

Progress Notes:

ACUTE - MEDICAL


PATIENT ID

CONSULTS

(To be completed by

individual discipline

and signed with

signature)

TRANSITIONAL PHASE

MULTIDISCIPLINARY TEAM

�� = Individual Disciplines have reviewed and

updates recorded accordingly

*PHYSIOTHERAPY

*OCCUPATIONAL THERAPY

*SPEECH/LANGUAGE PATHOLOGIST IF REQUIRED

*CLINICAL NUTRITION

*CCAC / DISCHARGE PLANNING

- assistive device needs identified and arranged

- home program developed and discussed

STROKE


*PHARMACIST

*SOCIAL WORKER

*OTHER:

��DATE &

TIMESIGNATURE


Review Jan 2013

VITAL SIGNS ACCORDING TO UNIT PROTOCOL

CHEST ASSESSMENT Q SHIFT ONLY IF DYSPHAGIC

PAIN ASSESSMENT PRN

SKIN INTEGRITY Q SHIFT

BRADEN RISK ASSESSMENT UPDATED

MONITOR BOWEL AND BLADDER ROUTINE

MODIFIED RANKIN SCALE IF PATIENT BEING DISCHARGED FROM ACUTE CARE

REASSESS DYSPHAGIA SCREENING TOOL IF INDICATED

OTHER:

TREATMENTS/

INTERVENTIONS

AMBULATION INDICATED ON KARDEX

DOCUMENT TOLERATED SITTING TIME DAILY

MULTIDICIPLINARY TEAM: RECOMMENDATIONS CLEARLY COMMUNICATED ON CARE PLAN

INITIALS:


STROKE

CLINICAL PATHWAY CHECKLISTPATIENT ID

ACUTE - MEDICAL

UPDATE PATIENT SAFETY CUES PRN

PROCESS

MAINTENANCE PHASE

BEYOND DAY 6 COMPLETED


"��" requires descriptive charting in progress notes

UPDATE THE PATIENT CARE PLAN ACCORDING TO THE FOLLOWING

LISTED CRITERIA, THEN DISCONTINUE THE STROKE PATHWAY.

CHARTING TO BE RESUMED ACCORDING TO UNIT CRITERIA.

FOR LONGER TERM PATIENTS CONSIDER OBTAINING ALC ORDERS

ASSESSMENT

(OBSERVATIONS/

MEASUREMENTS/

ELIMINATION)

IF NON-AMBULATORY, ANTI AMBOLI STOCKINGS/SEQUENTIAL COMPRESSION DEVICES

NUTRITION

� DIET TEXTURE AS PER DYSPHAGIA SCREENING TOOL

� REGULAR TEXTURE - HEALTHY HEART DIET

� SPECIAL DIET: ________________________

PUSH ORAL FLUIDS IF NOT NPO

DOCUMENTATION FOR TUBE FEEDING AND FEEDING TYPE

PATIENT SAFETY

CUES MRSA AND VRE SWABS Q WEEKLY (Next date to be completed indicated on Care Plan)

MOBILITY/ACTIVITY

ACTIVITY AS TOLERATED REVIEWED DAILY

TRANSFERS INDICATED ON CARE PLAN (SEE "HEALTHY MOVES" BOOKLET FOR

REFERENCE PURPOSES)


Review Jan 2013

PSYCHOSOCIAL

SUPPORT/

EDUCATION

UPON PATIENT DISCHARGE, REFER TO PATHWAY DISCHARGE CRITERIA SHEET

INITIALS:

Progress Notes:


STROKE

CLINICAL PATHWAY CHECKLISTPATIENT ID

ACUTE - MEDICAL

STROKE TEACHING ON GOING

PROCESS

MAINTENANCE PHASE

BEYOND DAY 6 COMPLETED


"��" requires descriptive charting in progress notes

DISCHARGE

PLANNING

ASSESS DISCHARGE CRITERIA DAILY

ONGOING STRATEGY TO OVERCOME BARRIERS TO DISCHARGE IN PLACE


Review Jan 2013

PROCESS INITIAL

4 DRIVING STATUS REVIEWED

5SECONDARY PREVENTION RISK

FACTORS ADDRESSED

LABORATORY /

DIAGNOSTICS

TREATMENTS/

INTERVENTIONS

NUTRITION

MOBILITY/ACTIVITY

CONSULTS



ACUTE - MEDICAL

REQUISITION FOR OUTPATIENT BLOOD WORK GIVEN

ASSESSMENT

(OBSERVATIONS/

MEASUREMENTS/

ELIMINATION)

STROKE

PATIENT ID

DISCHARGE CRITERIA DATE MET



SPEECH/LANGUAGE AND/OR SWALLOWING FOLLOW UP

ARRANGED IF NEEDED

PERFORMANCE

INDICATORS

PATIENT AWARE OF RISK FACTORS AND MANAGEMENT

PATIENT AND FAMILY AWARE OF MANAGEMENT PLAN

CAREGIVER TRAINING/EDUCATION COMPLETED

CCAC DISCHARGE PLAN COMPLETED

- ASSISTIVE DEVICES ARRANGED AND IN HOME

FOLLOW UP OUTPATIENT THERAPY AS APPROPRIATE

ALL CONSULTS COMPLETED

- NOTIFY COMMUNITY STROKE TEAM OF DISCHARGE THROUGH

REFERRAL PROCESS

TRANSFER INFORMATION CHECKLIST COMPLETED

REFERRAL TO STROKE PREVENTION CLINIC COMPLETED

PATIENT AND FAMILY HAVE UNDERSTANDING OF STROKE

EDUCATION

PSYCHOSOCIAL

SUPPORT/

EDUCATION

DISCHARGE TRANSPORTATION ARRANGED

SKIN INTEGRITY PLAN

NEED FOR COMMUNITY DIETITIAN REFERRAL IDENTIFIED

DISCHARE MEDICATIONS LIST EXPLAINED TO PATIENT AND FAMILY

BOWEL AND BLADDER ROUTINE ESTABLISHED

MEDICATIONS

DISCHARGE

PLANNING

PERSCRIPTION GIVEN

PATIENT / FAMILY INDICATE THEY UNDERSTAND MEDICATIONS

PATIENT AND FAMILY AWARE OF FOLLOW UP APPOINTMENT


Review Jan 2013

Progress Notes:

PATIENT ID


STROKE


ACUTE - MEDICAL


Review Jan 2013

stroke clinical pathway checklist acute - medical€¦ · initials date time-> alert 3.0 drowsy...

Documents