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1
ACUTE STROKE INTEGRATED CARE PATHWAY
ALL OTHER DISCIPLINES
The Pathway must be retained in the patient’s notes
and any additional documentation must
be attached behind this document.
This pathway is intended for guidance only. It is no way intended to be prescriptive.
Clinical decisions remain at the discretion of the clinician.
PATIENT NAME ____________________________________
H&C NUMBER ____________________________________
DATE OF BIRTH ____________________________________
CONSULTANT ____________________________________
REMEMBER TO:
Complete each section clearly and in full
Tick boxes where appropriate
Countersign each section
If ‘No’ is ticked record variance
3
If patient is receiving Thrombolysis treatment complete section A below, and pages 4-13 of care
pathway.
Tick as you deliver care, if ‘NO’ is ticked document reason in variation record on page 11.
Section A.
Patient attached to cardiac monitor: Yes No Abnormal arrhythmias observed in 1st 24 hours; Yes N/A If Yes reported to Dr and recorded in evaluation Yes N/A Time 1st syringe of Actilyse infused …………………… Time 2nd syringe of Actilyse infused…………………… N/A On completion of Actilyse, giving set flushed with 20mls normal saline over 30 seconds: Yes No GCS / MEWS observations recorded every 15mins from commencement of infusion for 3 hours: Yes No Then every 30 mins for 6 hours: Yes No Then hourly for 15 hours: Yes No
Observe for the following potential complications while recording GCS and MEWS observations, during ACTILYSE administration.
GCS score dropped by 2 or more (from baseline GCS) Blood pressure reading > 230/120 mm Hg 2 Blood pressure readings taken 5 minutes apart > 185/110 mm Hg (if BP reading is > 185/110, repeat 5 minutes later. If BP remains > 185/110 stop infusion) Signs / Symptoms of anaphylaxis (angioedema, hypotension, bronchospasm, uticaria, itch) Signs / Symptoms of intracerebral haemorrhage (headache, vomiting, seizures, hypertension) Signs / Symptoms of systemic haemorrhage (hypotension, tachycardia, clammy, sweating, haematuria, haemoptysis, abdominal distension etc)
If any of the above occurs during administration stop infusion and inform Dr immediately.
Repeat C.T imaging of brain ordered for 24 hours from completion of Actilyse infusion: Yes No
Date/Signature/ Designation…………………………………………………………………….
4
PATIENT DETAILS / NURSING STAFF TO COMPLETE
Name:...................................................…………Known as: ........……….……………………… Address…………………………………………………………………………………………………. Tel No.: ………………………..… DOB: …………… Age: ……………………. Religion: .................................... Occupation: ………………...…… Married Single Widowed Divorced Retired Employed Unemployed First language ……………………………………Interpreter required? Yes N/A
Date of Symptom onset: .…………....... Time of onset : ……………….........…............... Date / Time of admission to ward: ................................................................................... Property book: Yes N/A In safe: Yes N/A Identity bracelet: Yes No Allergies: Yes N/A If yes please specify: ______________________________________________________
Presenting reason for admission: ..........................................................………………...................……………................................ .....................................................................………………..........………….............................................
Baseline Observations
BP right arm lying ___________ BP left arm lying ___________ Pulse __________ GCS __________ Temp. _________ Record Blood Glucose ----------- Oxygen Saturation Level______________ If below 95% Doctor informed Yes No
Urinalysis Result ___________________________________________________________
MSU/CSU obtained: Yes N/A Results of CT Scan of brain: .............................................………............................................................…………………........ Infection control status on admission……………………………………………………………..
Date/Sign/Designation: ……………………………………………………………………………….
Next of Kin/Contact Person Name: ...................………….………......... Relationship: ……………………. Address: ......………………………............ Tel No: Day ……………………… ………………………………………………. Tel No: Night ……………………. Additional contact………………………………………………………………………….. GP: ………………………………………… Tel No: ……………………………. ................………………………...
5
REFERRALS TO ALL OTHER DISCIPLINES
Following receipt of referral patients must be assessed by clinical Professions within the timeframe specified by
their professional guidelines
**Swallow screening may also be performed by nursing staff trained in Regional Swallow Screen
Date of referral
Sign. Date Referral Received
Sign. Date of assessment
Sign.
Physiotherapy
Speech & Language Therapist:
Swallow **
Speech
Language
Dietician
Social Worker
OT
Stroke Nurse Specialist
6
Record of Investigations and Referrals
Date Investigations/ referrals
Sign/Desig Date Investigations/ Referrals
Sign/Designation
7
On Admission /First 24 hours/ Nursing staff to complete Tick as you deliver care, if ‘NO’ is ticked document reason in variation record on page 11.
Usual condition Pre-Stroke
Changes due to present condition Prescribed Nursing Interventions
Level of Consciousness Level of Consciousness Drowsy Semi-conscious (responds to speech fully) (not fully rousable)
Conscious Unconscious GCS / MEWS observations commenced: Yes No Frequency……….. ……………… OR as per Thrombolysis guidelines: Yes If GCS < 8 Dr informed: Yes N/A BM recorded: Yes No
Breathing Colour: …………………... Breathless: Lying Yes N/A Sitting Yes N/A On exertion Yes N/A Smokes: Yes N/A …………… per day Home 02: Yes N/A
Breathing Colour: ……………………………….. Breathless: Lying Yes N/A Sitting Yes N/A On exertion Yes N/A
Mobility Dependent Transfers with 2 Transfers with 1 Walks with 2 Walks with 1 Independent Appliances / prosthesis / Equipment , Specify : ……………………. ………………………………………
Mobility Bed rest Transfers with 2 Transfers with 1 Walks with 2 Walks with 1 Independent
Appliances / prosthesis / equipment Specify: …………………………………………. ……………………………………………………. Manual handling risk assessment form completed: Yes No Referred to physiotherapy: Yes No
Circulation Circulatory problems: Yes N/A Please state…………………
Circulation
8
Tick as you deliver care, if ‘NO’ is ticked document reason in variation record on page 11.
Date/Signature/ Designation…………………………………………………………………….
Usual condition Pre-Stroke Changes due to present condition Prescribed Nursing Interventions
Cleansing and Dressing Independent Assistance required, specify below: 1 Person 2 Persons Upper body washing Upper body dressing Lower body washing Lower body dressing Dentures: Top Bottom
Cleansing and Dressing Independent Assistance required , please specify below: 1 Person 2 Persons Upper body washing Upper body dressing Lower body washing Lower body dressing Dentures: Top Bottom Oral hygiene assessed Yes N/A State mouth care frequency: …………..…… Eye Care: Yes N/A (Refer to Royal Marsden procedure manual for eye care / mouthcare)
Referred to O.T: Yes No
Skin Condition (on admission)
Pressure ulcers: Yes N/A Other Skin Condition Specify……………………………….. …………………………………………
Skin Condition Braden Tool completed: Yes No Pressure ulcer prevention pathway / wound assessment completed Yes N/A Pressure mattress: Yes N/A if yes state type of mattress: ………………………………………………. Pressure cushion Yes N/A Repositioning guidelines Yes N/A
Communicating Visually Impaired Yes N/A Aids used: ……………………………………………… Hearing impaired Yes N/A Aids used: …………………………………… …………………………………………………. Speech difficulty Yes N/A Specify: …………………………………..…
Communicating Visually Impaired Yes N/A Aids used: ………………………….…………………….. ……………………………………………………………… Hemianopia Yes N/A Left Right: Speech Affected Yes N/A Specify: …………………………………….
9
Tick as you deliver care, if ‘NO’ is ticked document reason in variation record on page 11.
Date/Signature/ Designation…………………………………………………………………….
Usual condition Pre-Stroke
Changes due to present condition Prescribed Nursing Interventions
Eliminating Continent Urine Yes Incontinent of urine Yes Continent faeces Yes Incontinent of faeces Yes If incontinent describe nature of problem and management: ………………………………………………. ………………………………………………. Needs assistance toileting Yes Specify assistance needed: ………………………………………………. Catheter insitu Yes Date last renewed………………………. Reason for insertion…………………….
Eliminating Continent Urine Yes Incontinent of urine Yes Continent faeces Yes Incontinent of faeces Yes If incontinent, continence assessment / care plan commenced: Yes No Catheter inserted Yes N/A Reason for insertion …………………………………………….. (Refer to Royal Marsden Procedure Manuel for catheter care)
If patient is receiving Thrombolysis avoid insertion of catheter for 1st 24 hours from commencement of infusion
Eating and Drinking Special diet Yes Specify: ………………………………… Can prepare meals Yes Assistance feeding Yes If yes specify: ……………………………
Eating and drinking Referred to SALT: Yes No Swallow screen performed: Yes No Nil by mouth Yes No N/A All patients that receive Thrombolysis should fast for 24 hours from commencement of infusion Must completed: Yes No Special diet: Yes No N/A Specify: ……………………………………. Normal diet and fluids : Yes No Assistance feeding Yes No N/A If yes specify: ……………………………… I.V. fluids in progress Yes No I.V. cannula in situ: Yes No I.V. cannulation chart commenced: Yes No Fluid Balance Chart: Yes No All patients that receive Thrombolysis must avoid insertion of additional cannulas for 1st 24 hours from commencement of infusion
Mental Health Short term memory loss Yes History of Depressive illness Yes Aggression verbal/physical Yes Attends psychiatric clinic Yes
Mental Health Oriented Yes Aggression verbal/physical Yes Agitated Yes
10
Please complete if patient is in receipt of:
Social Assessment House Steps inside steps outside Bungalow/Downstairs flat Bathroom upstairs downstairs Upstairs flat Toilet upstairs downstairs Sheltered housing Ramps Residential Home Stair lift (Permanent / temporary) Nursing home (permanent / temporary)
Pets: Support from family carer: …………………………………………………………….
Living: Alone Main carer name:_________________________ With partner
Dependents Address:________________________________
With other family _______________________________________ Telephone number_______________________
Referred to social worker: Yes No N/A
Date/Signature/ Designation…………………………………………………………………….
M T W T F S S Comments
Home care support worker
(personal care)
Record number of carers
Home care (practical care)
Meals on wheels
Day Centre Name Centre
Day Hospital General
Day Hospital Psychiatric
District Nurse Reason for visits
Community Psychiatric Nurse
Respite Frequency
Other e.g. private home help
11
Nursing Summary Sheet
________________________________________________________________________________________
________________________________________________________________________________________
Previous Medical History
________________________________________________________________________________________
Current Medication _______________________________________________________________________
Date/Signature/ Designation…………………………………………………………………….
State variance Reason (if known) Date Signature/ Design
12
DAY ONE
Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
13
DAY ONE Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
14
PATIENT MANUAL HANDLING RISK ASSESSMENT (Hospital)
Physical Disability: Handling Constraints/Behaviour Previous Mobility: History of Falls: YES/NO
Weight, BMI & Height:
Patient independent for all activities YES/NO No further assessment required YES/NO Further assessment required post op: YES/NO Name & Destination: ______________________ (Please print) ____________________________ Signature: _________ _____________________ Date: ______________________________
DATE DATE DATE
Dependence Aid Hoist & Sling Dependence Aid Hoist & Sling Dependence Aid Hoist & Sling
Bed/Trolley to Bed
Up/down bed
Turning in bed
Lying to sitting
Bed/Chair to Chair/commode
Walking
Showering/ Bath
Other
Print Name & Designation:
Any other comments / instructions
Dependence Independent 0 Supervision S Assistance of 1 1 Assistance of 2 2 Assistance of 3 3 More than 3 state no.
Handling Aid Flat slide sheets FS Roller slide sheets RS Handling Belt HB Transfer board TB Stand Aid SA Other
Zimmer Z Rollator R Crutches C Walking Stick WS Bed profile BP
Hoist Mobile Hoist MH Overhead hoist OH Standing hoist SH Bariatric Hoist BH
Sling size/type Small S Medium M Large L Extra Large XL Standard St Toileting T Disposable D Other
15
PATIENT MANUAL HANDLING RISK ASSESSMENT - Continuation Sheet
DATE DATE DATE
Dependence Aid Hoist & Sling Dependence Aid Hoist & Sling Dependence Aid Hoist & Sling
Bed/Trolley to Bed
Up/down bed
Turning in bed
Lying to sitting
Bed/Chair to Chair/commode
Walking
Showering/Bath
Other
Print Name & Designation:
Any other comments / instructions
Dependence Independent 0 Supervision S Assistance of 1 1 Assistance of 2 2 Assistance of 3 3 More than 3 state no.
Handling Aid Flat slide sheets FS Roller slide sheets RS Handling Belt HB Transfer board TB Stand Aid SA Other
Zimmer Z Rollator R Crutches C Walking Stick WS Bed profile BP
Hoist Mobile Hoist MH Overhead hoist OH Standing hoist SH Bariatric Hoist BH
Sling size/type Small S Medium M Large L Extra Large XL Standard St Toileting T Disposable D Other
16
BRADEN SCALE – For Predicting Pressure Ulcer Risk (Initial assessment to be completed within 2 hours of admission)
AT RISK: 18 OR LESS > Commence Pressure Ulcer Prevention Pathway LOW RISK: 19 – 23
DATE OF ASSESS
SCORE/DESCRIPTION 1 2 3 4
RISK FACTOR
SENSORY PERCEPTION Ability to response meaningfully to pressure related discomfort
1.COMPLETELY LIMITED Unresponsive (does not moan, flinch or grasp) to painul stimuli, due to diminished level of sedation. OR Limited ability to feel pain over most of body surface.
2.VERY LIMITED Repsonds only to Painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR Has a sensory Impairment which limits the abilty to feel pain or discomfort over ½ of body.
3. SLIGHTLY LIMITED Reponds only 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.
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. VERY MOIST Skin is often, but not Always moist. Linen must be changed at least once a shift.
3. OCCASSIONALLY 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 bed.
2. CHAIRFAST Ability to walk, severely limited or non-existent. 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 the 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 2 hours during walking 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 change in body or extremity position independently.
4. NO LIMITATIONS Makes major and frequent changes in position without assistance.
NUTRITION Usual food intake pattern 1NPO: Nothing by
Mouth. 2IV: Intravenously
3TPN: Total
Parenteral nutrition.
1. VERY POOR Never eats a complete meal. rarely eats more that 1/3 of any food offered. eats two servings or less of protein (meat or dairy products) per day. Takes fluids poorly. does not take a liquid dietary supplement OR Is NPO
1 and/or maintained
on clear fluids or IV2 for more
than five days.
2. PROBABLY INADEQUATE Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products a day. Occasionally will take a dietary supplement. OR Receives less than optimum amount of liquid diet or tube feeding.
3. ADEQUATE Eats over ½ of most meals. Eats a total of 4 servings of protein (meat dairy products) each day. Occasionally will refuse a supplement if offered. OR Is on a tube feeding or TPN
3 regime 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 or dairy products. Occasionally eats between meals. does not require supplementation.
FRICTION & 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 Ppobably 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.
TOTAL SCORE
ASSESS DATE TIME SIGNATURE OF REGISTERED NURSE ASSESS DATE TIME SIGNATURE OF REGISTERED NURSE
1
3
2
4
17
MUST DOCUMENTATION COMPLETE ON ADMISSION:
Height…………….m Actual □ or Recalled □ Weight……………kg Actual □ or Recalled □
PRE-MUST QUESTIONS: Does the patient have :-
DATE
1 . A history of recent weight loss Yes / No Yes / No Yes / No
2. Altered/decreased appetite for 7 days or more
Yes / No Yes / No Yes / No
3. A risk of under nutrition due to current illness e.g. difficulty eating/drinking
Yes /No Yes / No Yes / No
4 A need for assistance with feeding Yes / No Yes / No Yes / No
SIGNATURE
If answer is No to all of the above questions repeat screening weekly. If answer is yes to any of the above questions then complete ‘Must’ below. Also repeat weekly.
Date
Weight (Kg) / MUAC (cm)
Height (m) / Ulna length (cm)
BMI
Score Score Score
STEP 1 BODY MASS INDEX-BMI
Over 20 0 0 0
18.5 to 20 1 1 1
Less than 18.5 2 2 2
STEP 2 UNPLANNED WEIGHT LOSS IN LAST 3-6 MONTHS
Less than 5% 0 0 0
Between 5-10% 1 1 1
More than 10% 2 2 2
STEP 3 ACUTE DISEASE
If patient is acutely ill AND there has been OR is likely to be no nutritional intake for more than 5 days
2 2 2
TOTAL MUST SCORE: Low Risk =0 Medium Risk =1
High Risk 2
Does the patient require assistance to maintain nutrition and hydration? Yes / No
18
Malnutrition Universal Screening Tool (MUST) Flowchart
LOW RISK MUST score = 0
MEDIUM RISK MUST score = 1
HIGH RISK MUST score = > 2
Record MUST Details
Recommend a WELL BALANCED DIET
Record MUST Details
Recommend High Protein / Energy Diet
Monitor intake for 3 days (record on food chart )
Record MUST Recordings
Refer to Dietitian Recommend High
Protein /Energy Diet Monitor intake as
per Dietitian (record on food chart)
RESCREEN Weekly
RESCREEN
1 week and refer to dietitian if risk status changes
19
DAY 2
Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Unless stated otherwise activities below to be completed by Nurse
Conscious Yes Unconscious Yes GCS observations recorded Yes No Frequency: …………………………. (Refer to Royal Marsden) Mews continued: Yes No Frequency……………………………. BM recorded: Yes No N/A
Hydration IV fluids in progress: : Yes No N/A Subcutaneous fluids in progress : Yes N/A Fluid Balance Chart Recorded: Yes No N/A I.V. cannula in situ Yes N/A If cannula in situ, I.V. cannulation chart reviewed Yes No
Nutrition: Nil by mouth Normal diet Modified Consistency (MC) Specify_____________________ Thickened Fluids (TF) PEG NG
If MC or TF referred to Dietician: Yes No
Food Chart : Yes No N/A
Mobility: Manual handling risk assessment form reviewed : Yes N/A
Bed Rest Up to sit Transfer with hoist Transfers with 1 Transfers with 2 Mobile with 1 Mobile with 2 Mobile with aid Mobile with supervision Independent
Date/Signature/ Designation…………………………………………………………………….
20
DAY 2
Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Cleansing and Dressing: Personal Hygiene Independent 1 Person 2 Persons Assistance required: Lower Half
Upper Half Bed bath Shower
Dressing Independent
1 Person 2 Persons Assistance required: Lower Half
Upper Half
Eye Care: Yes No N/A Mouth Care: Yes No N/A (Refer to Royal Marsden)
Skin Condition Pressure Mattress Yes No N/A If yes specify type: ……………………………… Pressure Relieving Cushion Yes No N/A If yes specify type: ……………………………… Wound assessment chart reviewed Yes No N/A
Elimination: Continent Urine: Yes Incontinent of urine: Yes Continent faeces: Yes Incontinent of faeces: Yes If incontinent, continence assessment continued / care plan reviewed Yes No SRC in situ Yes N/A If SRC in situ, catheter care performed Yes No (refer to Royal Marsden) Bowels opened Yes N/A
Date/Signature/ Designation…………………………………………………………………….
21
DAY 2 Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Pain Intervention: Has patient pain as per MEWS chart: Yes N/A If yes details recorded in evaluation. Yes No
Barriers to communication:
Sleep pattern documented in evaluation: Yes No (record duration of sleep, number of times awakened, why patient awakened etc)
Patient’s condition and pathway discussed with patient/family/carer: Yes No Details of conversation recorded in evaluation: Yes No
Physio to complete: Positioning:…………………………………………………………………………………………… Transfers:…………………………………………………………………………………………….. Mobility / Gait:………………………………………………………………………………………..
S&L Therapist to complete: Swallow assessment : Yes No N/A Communication assessment: Yes No N/A
O.T. to complete: Assessment and treatment commenced / continued: Yes No N/A
State variance Reason (if known) Date Signature
Date/Signature/ Designation…………………………………………………………………….
22
DAY 2 Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
23
DAY 2 Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
24
DAY 3 Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Unless stated otherwise activities below to be completed by Nurse
Conscious Yes Unconscious Yes GCS observations recorded Yes No N/A Frequency: ……………………… (Refer to Royal Marsden) Mews continued: Yes No N/A Frequency……………………………. BM recorded: Yes No N/A
Hydration IV Therapy in progress: : Yes N/A Subcutaneous fluids in progress: Yes N/A Fluid Balance Chart Recorded: Yes No N/A I.V. cannula in situ Yes N/A If cannula in situ, I.V. cannulation chart reviewed Yes No
Nutrition: Nil by mouth Normal diet Modified Consistency (MC) Specify_____________________ Thickened Fluids (TF) PEG NG
If MC or TF referred to Dietician: Yes No
Food Chart : Yes No N/A
Mobility: Manual handling risk assessment form reviewed : Yes N/A
Bed Rest Up to sit Transfer with hoist Transfers with 1 Transfers with 2 Mobile with 1 Mobile with 2 Mobile with aid Mobile with supervision Independent
Date/Signature/ Designation…………………………………………………………………….
25
DAY 3
Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Cleansing and Dressing: Personal Hygiene Independent 1 Person 2 People Assistance required: Lower Half
Upper Half Bed bath Shower
Dressing Independent
1 Person 2 Persons Assistance required: Lower Half
Upper Half
Eye Care Yes No N/A Mouth Care Yes No N/A (Refer to Royal Marsden)
Skin Condition Pressure Mattress Yes No N/A If yes specify type: ……………………………… Pressure Relieving Cushion Yes No N/A If yes specify type: ……………………………… Wound assessment chart reviewed Yes No N/A
Elimination: Continent Urine: Yes Incontinent of urine: Yes Continent faeces: Yes Incontinent of faeces: Yes If incontinent, continence assessment continued / care plan reviewed Yes No SRC in situ Yes N/A If SRC in situ, catheter care performed Yes No (refer to Royal Marsden) Bowels opened today: Yes Bowels opened in last 2 days: Yes Bowels not opened in 3 days Yes If Yes, Dr informed Yes No
Date/Signature/ Designation…………………………………………………………………….
26
DAY 3 Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Pain Intervention: Has patient pain as per MEWS chart: Yes N/A If yes details recorded in evaluation. Yes No
Barriers to communication: Sleep pattern documented in evaluation: Yes No (record duration of sleep, number of times awakened, why patient awakened etc)
Patient’s condition and pathway discussed with patient/family/carer: Yes No Details of conversation recorded in evaluation: Yes No
Physiotherapist to complete: Positioning:…………………………………………………………………………………………… Transfers:…………………………………………………………………………………………….. Mobility /Gait: ………………………………………………………………………………………..
S&L Therapist to complete: Swallow assessment : Yes No N/A Communication assessment: Yes No N/A
OT to complete: Assessment and treatment continued: Yes No N/A
State variance Reason (if known) Date Signature
Date / Signature / Designation__________________________________________________
27
DAY 3
Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
28
DAY 3
Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
29
DAY 4 Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Unless stated otherwise activities below to be completed by Nurse
Conscious Yes Unconscious Yes GCS observations recorded Yes N/A Frequency: ……………………… (Refer to Royal Marsden) Mews continued: Yes No N/A Frequency……………………………. BM recorded: Yes No N/A
Hydration IV Therapy in progress: Yes N/A Subcutaneous fluids in progress: Yes N/A Fluid Balance Chart Recorded: Yes N/A I.V. cannula in situ Yes N/A If cannula in situ, I.V. cannulation chart reviewed Yes No
Nutrition: Nil by mouth Normal diet Modified Consistency (MC) Specify_____________________ Thickened Fluids (TF) PEG NG
If MC or TF referred to Dietician: Yes No
Food Chart : Yes No N/A
Mobility: Manual handling risk assessment form reviewed : Yes N/A
Bed Rest Up to sit Transfer with hoist Transfers with 1 Transfers with 2 Mobile with 1 Mobile with 2 Mobile with aid Mobile with supervision Independent
Date/Signature/ Designation…………………………………………………………………….
30
DAY 4
Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Cleansing and Dressing: Personal Hygiene Independent 1 Person 2 People Assistance required: Lower Half
Upper Half Bed bath Shower
Dressing Independent
1 Person 2 Persons Assistance required: Lower Half
Upper Half
Eye Care Yes No N/A Mouth Care Yes No N/A (Refer to Royal Marsden)
Skin Condition Pressure Mattress Yes No N/A If yes specify type: ……………………………… Pressure Relieving Cushion Yes No N/A If yes specify type: ……………………………… Wound assessment chart reviewed Yes No N/A
Elimination: Continent Urine: Yes Incontinent of urine: Yes Continent faeces: Yes Incontinent of faeces: Yes If incontinent, continence assessment continued / care plan reviewed Yes No SRC in situ Yes N/A If SRC in situ, catheter care performed Yes No (refer to Royal Marsden) Bowels opened today: Yes Bowels opened in last 2 days: Yes Bowels not opened in 3 days Yes If Yes, Dr informed Yes No
Date/Signature/ Designation…………………………………………………………………….
31
DAY 4 Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Pain Intervention: Has patient pain as per MEWS chart: Yes N/A If yes details documented in evaluation. Yes No
Barriers to communication: Sleep pattern documented in evaluation: Yes No (record duration of sleep, number of times awakened, why patient awakened etc)
Patient’s condition and pathway discussed with patient/family/carer: Yes No Details of conversation recorded in evaluation: Yes No
Physio to complete: Positioning:…………………………………………………………………………………………… Transfers:…………………………………………………………………………………………….. Mobility /Gait: ………………………………………………………………………………………..
S&L Therapist to complete: Swallow assessment : Yes No N/A Communication assessment: Yes No N/A
OT to complete: Assessment and treatment continued: Yes No N/A
State variance Reason (if known) Date Signature
Date/Signature/ Designation…………………………………………………………………….
32
DAY 4
Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
33
DAY 4
Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
34
DAY 5
Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Unless stated otherwise activities below to be completed by Nurse
Conscious Yes Unconscious Yes GCS observations recorded Yes No N/A Frequency: ……………………… (Refer to Royal Marsden) Mews continued: Yes No N/A Frequency……………………………. BM recorded: Yes No N/A
Hydration IV Therapy in progress: Yes No N/A Subcutaneous fluids in progress: Yes N/A Fluid Balance Chart Recorded: Yes No N/A I.V. cannula in situ Yes N/A If cannula in situ, I.V. cannulation chart reviewed Yes No
Nutrition: Nil by mouth Normal diet Modified Consistency (MC) Specify_____________________ Thickened Fluids (TF) PEG NG
If MC or TF referred to Dietician: Yes No
Food Chart : Yes No N/A
Mobility: Manual handling risk assessment form reviewed : Yes N/A
Bed Rest Up to sit Transfer with hoist Transfers with 1 Transfers with 2 Mobile with 1 Mobile with 2 Mobile with aid Mobile with supervision Independent
Date/Signature/ Designation…………………………………………………………………….
35
DAY 5
Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Cleansing and Dressing: Personal Hygiene Independent 1 Person 2 People Assistance required: Lower Half
Upper Half Bed bath Shower
Dressing Independent
1 Person 2 Persons Assistance required: Lower Half
Upper Half
Eye Care Yes No N/A Mouth Care Yes No N/A (Refer to Royal Marsden)
Skin Condition Pressure Mattress Yes No N/A If yes specify type: ……………………………… Pressure Relieving Cushion Yes No N/A If yes specify type: ……………………………… Wound assessment chart reviewed: Yes No N/A
Elimination: Continent Urine: Yes Incontinent of urine: Yes Continent faeces: Yes Incontinent of faeces: Yes If incontinent, continence assessment continued / care plan reviewed Yes No SRC in situ Yes N/A If SRC in situ, catheter care performed Yes No (refer to Royal Marsden) Bowels opened today: Yes Bowels opened in last 2 days: Yes Bowels not opened in 3 days Yes If Yes, Dr informed Yes No
Date/Signature/ Designation…………………………………………………………………….
36
DAY 5 Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Pain Intervention: Has patient pain as per MEWS chart: Yes N/A If yes details documented in evaluation: Yes No Barriers to communication: Sleep pattern documented in evaluation: Yes No (record duration of sleep, number of times awakened, why patient awakened etc)
Patient’s condition and pathway discussed with patient/family/carer: Yes No Details of conversation recorded in evaluation: Yes No
Physiothearapist to complete: Positioning:…………………………………………………………………………………………. Transfers:…………………………………………………………………………………………… Mobility/ Gait:……………………………………………………………………………………….
S&L Therapist to complete: Swallow assessment : Yes No N/A Communication assessment: Yes No N/A
OT to complete: Assessment and treatment continued: Yes No N/A
State variance Reason (if known) Date Signature
Date/Signature/ Designation…………………………………………………………………….
37
DAY 5
Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
38
DAY 5
Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
39
DAY 6
Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Unless stated otherwise activities below to be completed by Nurse
Conscious Yes Unconscious Yes GCS observations recorded Yes No N/A Frequency: ……………………… (Refer to Royal Marsden) Mews continued: Yes No N/A Frequency……………………………. BM recorded: Yes No N/A
Hydration IV Therapy in progress: Yes N/A Subcutaneous fluids in progress: Yes No N/A Fluid Balance Chart Recorded: Yes N/A I.V. cannula in situ Yes N/A If cannula in situ, I.V. cannulation chart reviewed Yes No
Nutrition: Nil by mouth Normal diet Modified Consistency (MC) Specify_____________________ Thickened Fluids (TF) PEG NG
If MC or TF referred to Dietician: Yes No
Food Chart : Yes No N/A
Mobility: Manual handling risk assessment form reviewed : Yes N/A
Bed Rest Up to sit Transfer with hoist Transfers with 1 Transfers with 2 Mobile with 1 Mobile with 2 Mobile with aid Mobile with supervision Independent
Date/Signature/ Designation…………………………………………………………………….
40
DAY 6
Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Cleansing and Dressing: Personal Hygiene Independent 1 Person 2 Persons Assistance required: Lower Half
Upper Half Bed bath Shower
Dressing Independent
1 Person 2 Persons Assistance required: Lower Half
Upper Half
Eye Care Yes No N/A Mouth Care Yes No N/A (Refer to Royal Marsden)
Skin Condition Pressure Mattress Yes No N/A If yes specify type: ……………………………… Pressure Relieving Cushion Yes No N/A If yes specify type: ……………………………… Wound assessment chart reviewed: Yes No N/A
Elimination: Continent Urine: Yes Incontinent of urine: Yes Continent faeces: Yes Incontinent of faeces: Yes If incontinent, continence assessment continued /care plan reviewed Yes No SRC in situ: Yes N/A If SRC in situ, catheter care performed Yes No (refer to Royal Marsden) Bowels opened today: Yes Bowels opened in last 2 days: Yes Bowels not opened in 3 days Yes If Yes, Dr informed Yes No
Date/Signature/ Designation…………………………………………………………………….
41
DAY 6 Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Pain Intervention: Has patient pain as per MEWS chart: Yes N/A If yes document details in evaluation. Barriers to communication: Sleep pattern documented in evaluation: Yes No (record duration of sleep, number of times awakened, why patient awakened etc)
Patient’s condition and pathway discussed with patient/family/carer: Yes No Details of conversation recorded in evaluation: Yes No
Physio to complete: Positioning:…………………………………………………………………………………………. Transfers:…………………………………………………………………………………………… Mobility/Gait:………………………………………………………………………………………..
S&L Therapist to complete: Swallow assessment : Yes No N/A Communication assessment: : Yes No N/A
OT to complete: Assessment and treatment continued: Yes No N/A
State variance Reason (if known) Date Signature
Date/Signature/ Designation…………………………………………………………………….
42
DAY 6
Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
43
DAY 6
Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
44
DAY 7 Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Unless stated otherwise activities below to be completed by Nurse
Conscious Yes Unconscious Yes GCS observations recorded Yes No N/A Frequency: ……………………… (Refer to Royal Marsden) Mews continued: Yes No N/A Frequency……………………………. BM recorded: Yes No N/A
Hydration IV Therapy in progress: Yes No N/A Subcutaneous fluids in progress: Yes N/A Fluid Balance Chart Recorded: Yes No N/A I.V. cannula in situ Yes N/A If cannula in situ, I.V. cannulation chart reviewed Yes No
Nutrition: Nil by mouth Normal diet Modified Consistency (MC) Specify_____________________ Thickened Fluids (TF) PEG NG
If MC or TF referred to Dietician: Yes No
Food Chart : Yes No N/A
Mobility: Manual handling risk assessment form reviewed : Yes N/A
Bed Rest Up to sit Transfer with hoist Transfers with 1 Transfers with 2 Mobile with 1 Mobile with 2 Mobile with aid Mobile with supervision Independent
Date/Signature/ Designation…………………………………………………………………….
45
DAY 7
Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Cleansing and Dressing: Personal Hygiene Independent 1 Person 2 Persons Assistance required: Lower Half
Upper Half Bed bath Shower
Dressing Independent
1 Person 2 Persons Assistance required: Lower Half
Upper Half
Eye Care Yes No N/A Mouth Care Yes No N/A (Refer to Royal Marsden)
Skin Condition Pressure Mattress Yes No N/A If yes specify type: ……………………………… Pressure Relieving Cushion: Yes No N/A If yes specify type: ……………………………… Wound assessment chart reviewed: Yes No N/A
Elimination: Continent Urine: Yes Incontinent of urine: Yes Continent faeces: Yes Incontinent of faeces: Yes If incontinent, continence assessment continued / care plan commenced Yes No SRC in situ: Yes N/A If SRC in situ, catheter care performed Yes No (refer to Royal Marsden) Bowels opened Yes Bowels opened today: Yes Bowels opened in last 2 days: Yes Bowels not opened in 3 days Yes If Yes Dr informed Yes No
Date/Signature/ Designation…………………………………………………………………….
46
DAY 7
Tick as you deliver care, if ‘NO’ is ticked record why in variation record.
Pain Intervention: Has patient pain as per MEWS chart: Yes N/A If yes details documented evaluation. Yes No Barriers to communication: Sleep pattern documented in evaluation: Yes No (record duration of sleep, number of times awakened, why patient awakened etc)
Patient’s condition and pathway discussed with patient/family/carer: Yes No Details of conversation recorded in evaluation: Yes No
Physio to complete: Positioning:…………………………………………………………………………………………… Transfers:…………………………………………………………………………………………….. Mobility/Gait:………………………………………………………………………………………….
S&L Therapist to complete: Swallow assessment : ……………………………………………………………………………… Communication assessment: …………………………………………………………………….
OT to complete: Assessment and treatment continued: Yes No N/A
State variance Reason (if known) Date Signature
Date/Signature/ Designation…………………………………………………………………….
47
DAY 7 Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
48
DAY 7
Resus Status: ______________________________
Infection control precautions: Yes N/A
Date/Time Care progress/Evaluation Signature /Designation
49
DISCHARGE PLAN Date Signature/
Designation
Estimated date of discharge (to be completed within 24 hours of admission)
Discharge arrangements confirmed with patient / carer Yes N/A ________________________________________________________ ________________________________________________________ Record carers name:
Mode of transport (e.g ambulance, relative)
Time Ambulance booked:……… Booking number:……………. Target time:……………….. If ambulance is delayed Bed / Site Manager informed Yes
GP letter given and explained to patient / carer Yes
Medications given and explained to patient / carer Yes
Patients own medication returned to patient / carer Yes N/A
Patient has received written information re: discharge medications Yes
Patient property returned Yes N/A (record to whom this was given)
Out patient appointment given Yes N/A (record to whom appointment given)
Discharge advice given including point of contact should complications arise following discharge Yes
Tracker form completed Yes N/A
Ward returns book completed Yes
Cannula removed Yes N/A
Referred to District Nurse Yes N/A (Record reason eg. Continence management, wound management, Equipment etc)
Patient for discharge to Own Home Residential Home Nursing Home Relatives Home If discharge address is different to patients home address record new address:
Discharge Nurse: Time of discharge: Discharge Code:
Transfer of Patient to a Nursing Home or other Hospital
Transferred to:
Patient / Relative/ Carer informed Name:
Staff informed of transfer Name:
CREST transfer form completed By whom:
50
DISCHARGE PLAN
Speech and Language Therapist to complete
Date/ Sig
Communication/swallow advice to patient, carer Yes N/A
Addition of thickener to discharge medication list Yes N/A
SALT follow up required Yes N/A
Referred to Specialist Community Stroke Team: Yes No N/A
Physiotherapist to complete
Occupational Therapist to complete
Social Worker to complete
Services to be installed upon discharge: Date services to be commenced
Date / Sign
State variance Reason (if known) Date Signature
EQUIPMENT Date Ordered Signature Date delivered/Collected Signature
Walking stick Zimmer frame / Rollator Other
Mobility upon discharge: Independent Zimmer frame/rollator With supervision Uses wheelchair Walking stick Chair bound Has patient had a stair assessment Yes N/A Referred to Specialist Community Stroke Team: Yes No N/A
Date / Signature
Are equipment needs met for discharge Yes N/A
OT Home / Access Visit completed Yes N/A
OT discharge summary enclosed Yes N/A
Home exercise programme Yes N/A
Referred to Specialist Community Stroke Team: Yes No N/A