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� 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
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:
All Stroke patients over 18 years of age admitted to hospital.
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 Sep 2014© 2004-2014 Grey Bruce Health Network
1Review Sep 2016
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 Sep 2014© 2004-2014 Grey Bruce Health Network
2Review Sep 2016
PAIN ASSESSMENT: SCORE 0 - 10
URINE COLOUR:CATHETER TYPE AND SIZE:
OTHER:
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
ER PHASEON
TRANSFER
CHEST ASSESSMENT: C - Clear *A - Adverse sounds
ER ADMISSION SIGNATURE:
ER TRANSFER SIGNATURE:
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
__________
GREY BRUCE HEALTH NETWORK
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
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 3
Review Sep 2016
`
ADVANCE DIRECTIVE DISCUSSION ADDRESSED
CONSULTS
GREY BRUCE HEALTH NETWORK
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL PATIENT ID
PROCESS
EMERGENCY PHASE
0 - 3 HOURS ���� = Done ���� = Not Done N/A = Not Applicable
* requires descriptive charting in progress notes
OTHER:
MOBILITY/ACTIVITYBED REST
OTHER:
TREATMENTS/
INTERVENTIONS
IV SITE ESTABLISHED / INSITU AND SATISFACTORY
2ND IV SITE ESTABLISHED / INSITU AND SATISFACTORY
OTHER:
TRANSFER
STROKE
PSYCHOSOCIAL
SUPPORT/
EDUCATION
PATIENT / FAMILY INFORMED OF DIAGNOSIS / REASON FOR
ADMISSION
ADDRESS IMMEDIATE CONCERNS
NUTRITIONNPO
DATE / TIME
__________
DATE / TIME
__________
ER PHASEON
TRANSFER
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
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:
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 4
Review Sep 2016
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
Updated Jan 2011 © 2004-2011 Grey Bruce Health Network6
Review Jan 2013
(A) Face -
(B) Arm -
(B) Arm - 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.
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.
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.
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.
(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
Updated Jan 2011 © 2004-2011 Grey Bruce Health Network7
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
- 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.
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.
- 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.
ii) Dorsi Flexion of foot. Have patient point toes and foot upwards. Apply resistance to one foot at a
time, to test for weakness.
Updated Jan 2011 © 2004-2011 Grey Bruce Health Network8
Review Jan 2013
INITIALS:
CATHETER
REMOVED:
INITIALS:
URINE COLOUR:
1
RESTRAINT OBSERVATION Q _______ MIN
TREAT TEMPS >37.5 * NOTIFY PHYSICIAN FOR TEMP > 38.5
CHEST ASSESSMENT Q4H: C - Clear * A - Adverse sounds
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
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
���� = Done ���� = Not Done N/A = Not Applicable
* requires descriptive charting in progress notes
PERFORMANCE
INDICATORS
GREY BRUCE HEALTH NETWORK
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL PATIENT ID
STROKE
Pass / Fail keep NPO
DAY 3
DATE:
� Met � Not Met � N/ADYSPHAGIA SCREENING TOOL
COMPLETED (Once Q24H)
MODIFIED RANKIN SCALE (Indicate Score)
BRADEN (SKIN) RISK ASSESSMENT COMPLETED
ON ADMISSION AND PRN (Indicate Score)
PATIENT SAFETY
CUES
OTHER:
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
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)
* CONSENT OBTAINED FOR MINIMAL RESTRAINT FOR SAFETY AND
REASSESSED Q24H
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 9
Review Sep 2016
SLEEP: R - Restless F - Fair W - Well
PERSONAL HYGIENE:
C - Complete / Cueing required A - Assist S - Self
OTHER:
NUTRITION
OTHER:
ALTERNATE ROUTES DETERMINED FOR MEDS IF PATIENT NPO
PROCESS
ACUTE CARE PHASE
INITIALS:
NON-THROMBOLYTIC - ACTIVITY AS TOLERATED
THROMBOLYTIC - RESTRICTED AS ORDERED X 24 HOURS
* 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:
MOBILITY /
ACTIVITY SPECIAL EQUIPMENT:
GREY BRUCE HEALTH NETWORK
STROKE
CLINICAL PATHWAY CHECKLIST
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
DATE:
DAY 1 DAY 2 DAY 3
ACUTE - MEDICAL PATIENT ID
(Record Q4H on Checklist) DATE: DATE:
* 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
���� = Done ���� = Not Done N/A = Not Applicable
* requires descriptive charting in progress notes
NG FEEDING ESTABLISHED / CLINICAL NUTRITION CONSULT
PROTOCOL INITIATED / ENTER FEEDING ORDER SET INITIATED
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 10
Review Sep 2016
DISCHARGE
PLANNING
Progress Notes:
GREY BRUCE HEALTH NETWORK
STROKE
INITIALS:
ACUTE CARE PHASE
(Record Q4H on Checklist)
���� = Done ���� = Not Done N/A = Not Applicable
* requires descriptive charting in progress notes
* 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
PROCESSDATE: DATE: DATE:
DAY 1 DAY 2 DAY 3
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL PATIENT ID
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 11
Review Sep 2016
Progress Notes:
GREY BRUCE HEALTH NETWORK
STROKE
* CLINICAL NUTRITION
* PHARMACIST
* OTHER:
* CCAC / DISCHARGE PLANNING
* SOCIAL WORKER
PATIENT ID
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL
* SPEECH/LANGUAGE PATHOLOGIST IF REQUIRED
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
����DATE &
TIMESIGNATURE
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 12
Review Sep 2016
� 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
-Monitoring of pressure point areas -Dietitian
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)
Document reassessment
weekly on Kardex
-Physiotherapy
-Continence management -Occupational Therapy
-Activity level (i.e. turning, positioning)
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:
GREY BRUCE HEALTH NETWORK
CLINICAL PATHWAY
ACUTE - MEDICAL
Braden Risk Assessment
STROKE
SCORING (Key on Reverse)
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 14
Review Sep 2016
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.
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 15
Review Sep 2016
INITIAL DATE
2
3
OTHER:
INITIALS:
MORSE FALL RISK ASSESSMENT *I - Interventions required
*CONSENT OBTAINED FOR MINIMAL RESTRAINT FOR SAFETY
AND REASSESSED Q24H
OTHER:
RESTRAINT OBSERVATION Q ______ MINUTES
LABORATORY /
DIAGNOSTICS
ASSESSMENT
(OBSERVATIONS/
MEASUREMENTS/
ELIMINATION)
MODIFIED RANKIN SCALE IF PATIENT BEING DISCHARGED
FROM ACUTE CARE (Indicate Score)
BRADEN (SKIN) RISK ASSESSMENT UPDATED
PATIENT SAFETY
CUES
(UPDATED - PRN)
PATIENT SAFETY CUE CARDS IN PLACE IN ROOM
(no straws, acute stroke checklist, fall risk symbol)
(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
DAY:
���� = Done ���� = Not Done N/A = Not Applicable
* required descriptive charting in progress notes
� Met � Not Met � N/A
PROCESS
TRANSITIONAL PHASE DAY: DAY:
DATE: DATE: DATE:
INTERDISCIPLINARY CONSULTS
COMPLETED� Met � Not Met � N/A
TRIAGE (TRANSITION PLAN)
COMPLETED
GREY BRUCE HEALTH NETWORK
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL
STROKE
PATIENT ID
PERFORMANCE
INDICATORS
BLOOD WORK
DIAGNOSTICS
OTHER:
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 16
Review Sep 2016
INITIALS:
IF TUBE FEEDING T - Tolerated *A - Adjustments as ordered
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)
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
DATE: DATE:
ACUTE - MEDICAL PATIENT ID
PROCESS
DAY: DAY:
(Record Q4H on Checklist) DATE:
DAY:
� 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)
% OF DIET TAKEN IF NOT NPO
TRANSITIONAL PHASE
���� = Done ���� = Not Done N/A = Not Applicable
* required descriptive charting in progress notes
GREY BRUCE HEALTH NETWORK
STROKE
CLINICAL PATHWAY CHECKLIST
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 17
Review Sep 2016
INITIALS:
Progress Notes:
CAREGIVER TRAINING/EDUCATION CHECKLIST COMPLETED
AND UNDERSTOOD BY CAREGIVER
REFERRAL TO CCAC DISCHARGE PLANNING INITIATED
DATE / TIME:
DISCHARGE
PLANNING
ASSESS DISCHARGE CRITERIA DAILY AND NOTIFY
COMMUNITY STROKE TEAM WHEN PATIENT DISCHARGED
���� = Done ���� = Not Done N/A = Not Applicable
* required descriptive charting in 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
ACUTE - MEDICAL PATIENT ID
PROCESS
DAY: DAY: DAY:
DATE:
GREY BRUCE HEALTH NETWORK
STROKE
DATE: DATE:
(Record Q4H on Checklist)
CLINICAL PATHWAY CHECKLIST
TRANSITIONAL PHASE
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 18
Review Sep 2016
Progress Notes:
*CCAC / DISCHARGE PLANNING
- assistive device needs identified and arranged
- home program developed and discussed
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
STROKE
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL
GREY BRUCE HEALTH NETWORK
SIGNATURE
*PHARMACIST
*SOCIAL WORKER
*OTHER:
����DATE &
TIME
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 19
Review Sep 2016
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:
GREY BRUCE HEALTH NETWORK
STROKE
CLINICAL PATHWAY CHECKLISTPATIENT ID
ACUTE - MEDICAL
UPDATE PATIENT SAFETY CUES PRN
PROCESS
MAINTENANCE PHASE
BEYOND DAY 6 COMPLETED
���� = Done ���� = Not Done N/A = Not Applicable
"����" 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
ACTIVITY AS TOLERATED REVIEWED DAILY
TRANSFERS INDICATED ON CARE PLAN (SEE "HEALTHY MOVES" BOOKLET FOR
REFERENCE PURPOSES)
PATIENT SAFETY
CUES MRSA AND VRE SWABS Q WEEKLY (Next date to be completed indicated on Care Plan)
MOBILITY/ACTIVITY
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 20
Review Sep 2016
PSYCHOSOCIAL
SUPPORT/
EDUCATION
UPON PATIENT DISCHARGE, REFER TO PATHWAY DISCHARGE CRITERIA SHEET
INITIALS:
Progress Notes:
GREY BRUCE HEALTH NETWORK
STROKE
CLINICAL PATHWAY CHECKLISTPATIENT ID
ACUTE - MEDICAL
STROKE TEACHING ON GOING
PROCESS
MAINTENANCE PHASE
BEYOND DAY 6 COMPLETED
���� = Done ���� = Not Done N/A = Not Applicable
"����" requires descriptive charting in progress notes
DISCHARGE
PLANNING
ASSESS DISCHARGE CRITERIA DAILY
ONGOING STRATEGY TO OVERCOME BARRIERS TO DISCHARGE IN PLACE
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 21
Review Sep 2016
PROCESS INITIAL
4 DRIVING STATUS REVIEWED
5SECONDARY PREVENTION RISK
FACTORS ADDRESSED
LABORATORY /
DIAGNOSTICS
TREATMENTS/
INTERVENTIONS
NUTRITION
MOBILITY/ACTIVITY
CONSULTS
PERFORMANCE
INDICATORS
DATE MET
� Met � Not Met � N/A
� Met � Not Met � N/A
SPEECH/LANGUAGE AND/OR SWALLOWING FOLLOW UP
ARRANGED IF NEEDED
TRANSFER INFORMATION CHECKLIST COMPLETED
GREY BRUCE HEALTH NETWORK
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL
REQUISITION FOR OUTPATIENT BLOOD WORK GIVEN
ASSESSMENT
(OBSERVATIONS/
MEASUREMENTS/
ELIMINATION)
STROKE
PATIENT ID
DISCHARGE CRITERIA
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
DISCHARE MEDICATIONS LIST EXPLAINED TO PATIENT AND FAMILY
BOWEL AND BLADDER ROUTINE ESTABLISHED
MEDICATIONS
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
DISCHARGE
PLANNING
PERSCRIPTION GIVEN
PATIENT / FAMILY INDICATE THEY UNDERSTAND MEDICATIONS
PATIENT AND FAMILY AWARE OF FOLLOW UP APPOINTMENT
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 22
Review Sep 2016
Progress Notes:
PATIENT ID
GREY BRUCE HEALTH NETWORK
STROKE
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL
Updated Sep 2014© 2004-2014 Grey Bruce Health Network 23
Review Sep 2016