acute stroke integrated care · pdf fileacute stroke integrated care pathway ... patient...

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

2

DATE DAY

DAY 1

DAY 2

DAY 3

DAY 4

DAY 5

DAY 6

DAY 7

PRINT NAME DESIGNATION DATE / SIGNATURE

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…………………………………………………………………….

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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: ……………………………. ................………………………...

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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

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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



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


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 _______________________________________________________________________


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: ______________________________



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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

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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

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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

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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

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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

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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


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DAY 2


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


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


22

DAY 2 Resus Status: ______________________________



23

DAY 2 Resus Status: ______________________________



24



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







25

DAY 3


Cleansing and Dressing: Personal Hygiene Independent 1 Person 2 People Assistance required: Lower Half




Upper Half

Eye Care Yes No N/A Mouth Care Yes No N/A (Refer to Royal Marsden)


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


26


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)


Physiotherapist to complete: Positioning:…………………………………………………………………………………………… Transfers:…………………………………………………………………………………………….. Mobility /Gait: ………………………………………………………………………………………..


OT to complete: Assessment and treatment continued: Yes No N/A


Date / Signature / Designation__________________________________________________

27

DAY 3

Resus Status: ______________________________



28

DAY 3

Resus Status: ______________________________



29



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







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DAY 4






Upper Half





31


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)


Physio to complete: Positioning:…………………………………………………………………………………………… Transfers:…………………………………………………………………………………………….. Mobility /Gait: ………………………………………………………………………………………..





32

DAY 4

Resus Status: ______________________________



33

DAY 4

Resus Status: ______________________________



34

DAY 5




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







35

DAY 5






Upper Half


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



36


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)


Physiothearapist to complete: Positioning:…………………………………………………………………………………………. Transfers:…………………………………………………………………………………………… Mobility/ Gait:……………………………………………………………………………………….





37

DAY 5

Resus Status: ______________________________



38

DAY 5

Resus Status: ______________________________



39

DAY 6




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







40

DAY 6






Upper Half


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


41


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)


Physio to complete: Positioning:…………………………………………………………………………………………. Transfers:…………………………………………………………………………………………… Mobility/Gait:………………………………………………………………………………………..

S&L Therapist to complete: Swallow assessment : Yes No N/A Communication assessment: : Yes No N/A




42

DAY 6

Resus Status: ______________________________



43

DAY 6

Resus Status: ______________________________



44




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







45

DAY 7






Upper Half


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


46

DAY 7


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)


Physio to complete: Positioning:…………………………………………………………………………………………… Transfers:…………………………………………………………………………………………….. Mobility/Gait:………………………………………………………………………………………….

S&L Therapist to complete: Swallow assessment : ……………………………………………………………………………… Communication assessment: …………………………………………………………………….




47

DAY 7 Resus Status: ______________________________



48

DAY 7

Resus Status: ______________________________



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


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

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