chronic obstructive pulmonary disease … · clinical pathway checklist process ... if patient co 2...

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DISCUSSION BEGUN RE: CODE STATUS OR LIMITS TO INTERVENTIONS

DISCHARGED PATIENT HAS CCAC REFERRAL, WITH PERMISSION

ER TRANSFER SIGNATURE:

DISCHARGED PATIENT UNDERSTANDS THE NEED FOR SPIROMETRY

APPOINTMENT FOR FOLLOW-UP, IF NO PREVIOUS RESULTS

ER ADMISSION SIGNATURE:

CHRONIC OBSTRUCTIVE

PULMONARY DISEASE

CXR ABG's ECG

DISCHARGED PATIENT HAS BLUE COPD FOLDER WHICH INCLUDES THE

PLAN OF ACTION ON WHEN TO RETURN TO ER IF NECESSARY

OTHER:

BEST MEDICINE RECONCILIATON BEFORE DISHCARGE TO ASSESS FOR

PATIENT ADMINISTRATION KNOWLEDGE

DISCHARGED PATIENT UNDERSTANDS TO FOLLOW-UP WITH PRIMARY

PRACTITIONER WITHIN 1 WEEK

ABLE TO MOBILIZE SHORT DISTANCE BEFORE DISCHARE (e.g.. 6 MINUTE

WALK TEST) TO CONSIDER FOR DISCHARGED PATIENTS

MEDICATIONS

ANTIBIOTIC GIVEN WITHIN ONE HOUR OF PRESENTATION

VTE ASSESSMENT COMPLETED FOR ADMISSION

MOBILITY/

ACTIVITY

OTHER:

CAM TOOL COMPLETED

LABORATORY /

DIAGNOSTICS

ABNORMAL BLOOD WORK RESULTS REPORTED

(CBC, ELECTROLYTES, UREA, CREATININE, GLUCOSE)

CULTURE SPUTUM:

DISCHARGE

FROM ER

SATS ORDERED TO BE MAINTAINED: � > 92% � 88% - 92%

Notify physician if oxygen requirement exceeds 50%

DOCUMENT NOTIFICATION TIME OF PHYSICIAN FOR DYSPNEA SCALE >

7, TEMPERATURE > 38.5 SIGNS OF HYPO/HYPERTENSION, SATS < 88%

REPORTED TO

INPUT UNIT

ASSESSMENT

INITIAL VITAL SIGNS INCLUDE O2 SATS & TEMPERATURE BEFORE

LEAVING DEPARTMENT

* CHEST ASSESSMENT - RATE, COUGH, PRODUCTIVE (COLOUR NOTED),

EFFORT & HYPOVENTILATION

* BRONCHODILATOR EFFECT PRE & POST DOSE(S) DOCUMENTED

If patient CO2 retainer, consider compressed air for nebulization.

GREY BRUCE HEALTH NETWORK

CLINICAL PATHWAY CHECKLIST

PROCESS

ER DISCHARGE/ADMISSION CHECKLIST DATE/TIME DATE/TIME

�� = Done/Yes �� = Not Done/No N/A = Not Applicable

* requires descriptive charting in progress notes ER DISCHARGE

Updated Apr 2013© 2006 - 2013 Grey Bruce Health Network 1

Review Apr 2016

TEMPERATURE < 37.5 'C x 48 HOURS

DYSPNEA SCALE SCORE IMPROVING

ECG WITH CHEST PAIN AND NOTIFY PHYSICIAN

VTE PROPHYLAXIS REASSESSED Q48H

PROGRESS NOTES:

OXYGEN REQUIREMENTS APPROACHING PRE-ADMIT BASELINE

DIAGNOSTICS/

LABORATORY

BLOOD WORK DONE

OTHER:

MEDICATIONS

INTERMITTENT SET / IV (monitored hourly) AS ORDERED,

REASSESS DAY 2

OTHER:

DYSPNEA SCALE AT REST (Indicate highest score)

MENTAL STATUS (TIME, PLACE, PERSON)

CAM TOOL COMPLETED

ISOLATION: DROPLET/CONTACT PRECAUTIONS

(For initiation and discontinuation, Cerner order entered)

MONITOR POC FOR DIABETICS RECEIVING STEROID THERAPY

MONITOR INTAKE / OUTPUT

OTHER:

DATE


* requires descriptive charting in progress notes

Performance

IndicatorsOnce all Performance

Indicators are achieved move

to Phase 2.

RESPIRATORY RATE < 26 x 48 HOURS

ASSESSMENT

(OBSERVATIONS/

MEASUREMENTS/

ELIMINATION)

VS Q4H X 24H; QID X 24H, INCLUDING O2 SATS THEN BID & PRN

CHEST ASSESSMENT Q4H - BREATH SOUNDS, PRODUCTIVE COUGH

(COLOUR), USE OF ACCESSORY MUSCLES, EFFORT, ETC

* BRONCHODILATOR EFFECT PRE & POST DOSE(S) DOCUMENTED

If patient CO2 retainer, consider compressed air for nebulization.

PATIENT HAS BEEN TAUGHT AND INDICATES UNDERSTANDING OF

DYSPNEA SCORE

DYSPNEA SCALE WITH ACTIVITY (Indicate highest score)

INITIALS


CHRONIC OBSTRUCTIVE

PULMONARY DISEASECLINICAL PATHWAY

PROCESS

PHASE 1 - ADMISSION/ACUTE PHASE (Approximately 3 days)

DATE DATE

Updated Apr 2013 © 2006 - 2013 Grey Bruce Health Network

2

Review Apr 2016

DNR WISHES DISCUSSION ADDRESSED AND RECORDED

OTHER:

OTHER:

SMOKING CESSATION INFO HAS BEEN GIVEN / REINFORCED

OTHER:

PROGRESS NOTES:

CCAC REFERRAL ON ALL COPD DIAGNOSED PATIENTS, WITH

PERMISSION

OTHER:

DISCHARGE

PLANNING


CHRONIC OBSTRUCTIVE


MOBILITY/ACTIVITY

ASSIST PERSONAL HYGIENE

PSYCHOSOCIAL

SUPPORT

ASSESS ANXIETY AND INTERVENE

EDUCATION

REVIEW PATIENT PATHWAY

START AND CONTINUE WITH TEACHING CHECKLIST

ASSESS DISCHARGE CRITERIA DAILY

BRPs WITH ASSISTANCE, INCREASE TO AAT

WALK IN HALLWAY DAILY WITH GOAL OF 9 METERS QSHIFT

BEFORE DISCHARGE

PROCESS

PHASE 1 - ADMISSION/ACUTE PHASE (Approximately 3 days)

NUTRITION

REGULAR DIET OR SPECIAL DIET ____________________________,

NUTRITION INTAKE A - Adequate IN - INadequate

ENCOURAGE FLUIDS 2 - 3 LITRES/DAY

DATE



DATE DATE

INITIALS


3

Review Apr 2016

PROGRESS NOTES:

RESPIRATORY CONSULT

SOCIAL WORK CONSULT

SPEECH THERAPY / SWALLOWING CONSULT

WOUND CLINICIAN CONSULT

OTHER:

OTHER:

MULTIDICIPLINARY CONSULTS

CCAC CONSULT

CLINICAL NUTRITION CONSULE

OCCUPATIONAL THERAPY CONSULT

PHARMACY CONSULT

PHYSIOTHERAPY CONSULT

DATE OF

ASSESSMENT /

SIGNATURE

DATE OF

CONSULT

ASSESS SUPPORT SYSTEMS FOR PATIEN (FAMILY, FRIENDS, FINANCES, ETC) AND ENGAGE

MULTIDISCIPLINARY TEAM AS NEEDED (PHYSICIAN ORDER REQUIRED FOR TREATMENT)


CHRONIC OBSTRUCTIVE



4

Review Apr 2016


CHRONIC OBSTRUCTIVE

PULMONARY DISEASE

CHEST ASSESSMENT DOCUMENTATION PAGE

DATE: ____________ TIME: __________ INITIAL: _______

DYSPNEA SCORE: Activity _______ Rest _______



PATIENT ID










Review Apr 2016

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.

LEGEND:

W - WHEEZES

C - CRACKLES

A - ABSENT BREATH SOUNDS

0 - Nothing at allNOTIFY PHYSICIAN IF NOT RESOLVED WITH

BRONCHODILATOR:

1 - Very slight 7 - Very severe

DYSPNEA SCALE

3 - Moderate NOTIFY PHYSICIAN IMMEDIATELY IF:

4 - Somewhat severe 9 - Very, very severe (almost maximal)

Maintain Sats Between:

6 -

5 - Severe 10 - Maximal

SAMPLE

POSTERIOR VIEW (LEFT/RIGHT)

2 - Slight 8 -

Baseline Oxygen Requirements:

INSTRUCTIONS FOR CHEST ASSESSMENT DOCUMENTATION PAGE:

On the diagram, record the various lung sounds heard using a series of legend-identified symbols.

WW

C C

C C

C C

C C

L R

Updated Apr 2013 © 2006 - 2013 Grey Bruce Health Network Review Apr 2016

OTHER:

INITIALS

PROGRESS NOTES:

PROCESS

OFF SUPPLEMENTAL OXYGEN OR ON USUAL HOME O2

DATE

LABORATORY /

DIAGNOSTIC

CXR IF NOT IMPROVING

OTHER:

CONSULTS

VS BID ONCE STABLE & PRN, INCLUDING O2 SATS

HOME O2 THERAPY AS NEEDED (ABG RESULTS REQUIRED)

DYSPNEA SCALE AT REST

CAM TOOL

OTHER:

ABG’s

DYSPNEA SCALE WITH ACTIVITY

ISOLATION DISCONTINUED & ORDER ENTERED IN CERNER

CHEST ASSESSMENT (BREATH SOUNDS, PRODUCTIVE COUGH)

PHASE 2 - MAINTENANCE PHASE(Approximately 2 days)

DATE

PATIENT INDICATES KNOWLEDGE OF CHRONIC DISEASE MANAGEMENT

AND DISCHARGE PLAN



DATE

ASSESSMENT

(OBSERVATIONS/

MEASUREMENTS/

ELIMINATION)


CHRONIC OBSTRUCTIVE


DYSPNEA SCALE SCORE < 5

ACTIVITY LEVEL AS PER PREADMISSION

USUAL MENTAL STATUS

TEMPERATURE LESS THAN 37.5° C

PERFORMANCE

INDICATORS (DISCHARGE READINESS)


Review Apr 2016

ASSESS PROPER USE OF INHALERS

INITIALS

PROGRESS NOTES:

DATE



PATIENT OWNED PORTABLE OXYGEN AVAILABLE FOR DISCHARGE

BRONCHODILATOR TREATMENT EFFECTIVE AND ASSESSED QSHIFT

PATIENT ABLE TO AMBULATE AS TOLERATED

CHRONIC OBSTRUCTIVE

PULMONARY DISEASE

ADEQUATE DIET INTAKE AND ENCOURAGE FLUIDS 2 - 3 LITRES/DAY

DIET SUPPLEMENTS IF INADEQUATE NUTRITION

MOBILITY /

ACTIVITY

PATIENT ABLE TO COMPLETE ADL'S WITH MINIMAL ASSISTANCE

TRANSPORTATION ARRANGED FOR PENDING DISCHARGE

REVIEW DISCHARGE PLANS WITH PATIENT

CCAC ENGAGED AND EQUIPMENT AND SUPPORTS IDENTIFIED PRE-

DISCHARGE

REINFORCE SMOKING CESSATION EDUCATION

NUTRITION

DISCHARGE

READINESS

PROCESS

PHASE 2 - MAINTENANCE PHASE(Approximately 2 days)

START AND CONTINUE WITH TEACHING CHECKLIST

OTHER: TREATMENTS/

INTERVENTIONSOTHER:

REVIEW PATIENT PATHWAY

EDUCATION


CLINICAL PATHWAY

DATE DATE


Review Apr 2016

PROCESS INITIAL

MENTAL STATUS NORMAL FOR PATIENT

DIAGNOSTICS/

LABORATORY

FOLLOW-UP APPOINTMENT WITHIN 1 WEEK OF DISCHARGE

FOLLOW UP CHEST X-RAY

PHASE 3 - DISCHARGE CHECKLIST

DISCHARGE MEDICATION RECONCILIATION LIST REVIEWED AND PLACED IN

PATIENT'S BLUE COPD FOLDER

CCAC AWARE OF DISCHARGE DATE

PATIENT ADVISED TO FOLLOW UP WITH INFLUENZA AND PNEUMOCOCCAL

VACCINE

ASSESSMENTS

PSYCHOSOCIAL

SUPPORT/

EDUCATION


CHRONIC OBSTRUCTIVE


BLUD COPD FOLDER AND PATIENT PATHWAY HOME WITH PATIENT

O2 SATS >90% OR AS ORDERED - WITHIN PATIENT'S NORM X 48 HOURS

DYSPNEA SCALE NORMAL FOR PATIENT AND < 5

STABLE COMORBID ILLNESS

DISCHARGE

PLANNING

SCRIPT GIVEN

PATIENT/FAMILY QUESTIONS ANSWERED

IMPORTANCE OF SMOKING CESSATION REINFORCED, IF APPLICABLE

MEDICATIONS PATIENT DEMONSTRATES ACCURATE USE OF METERED DOSE INHALER

TEACHING CHECKLIST COMPLETE - COPY TO BLUE COPD FOLDER

PATIENT DEMONSTRATES KNOWLEDGE OF COPD EXACERBATION WARNING

SIGNS - PLAN OF ACTION


Review Apr 2016

DATE INITIALNEEDS

REINFORCEMENT

What is COPD?

Managing COPD

Breathing Techniques

Know Your Medications

How To Use Puffers

(Inhaler-Spacer Teaching Checklist)

Smoking Cessation

(Journey 2 Quit)

Vaccinations

Home O2

(O2 Manufactures Information)

Follow Up With Doctor / Tests

Recognizing Flare Ups

Action Plan

All rights reserved. No part of this document may be reproduced or transmitted

in any form or by any means, without the prior permissin of the copyright owner.

� COPD Flare-Ups, The Lung Association � The BreathworksTM Plan Booklet

� Canadian Respiratory Guidelines - Plan of Action � COPD Patient Pathway - EBC Program

� Journey 2 Quit - Smoking Cessation Book, The Lung Association

COMMENTS: (i.e. patient understanding)

GREY-BRUCE HEALTH NETWORK

CHRONIC OBSTRUCTIVE

PULMONARY DISEASE (COPD)

TEACHING CHECKLIST

Resources:

� COPD - Circle of Care Booklet, The Lung Association � Inhaler-Spacer Teaching Checklist

Updated May 2013 © 2003 -2013 Grey Bruce Health Network Review May 2016


EVIDENCE-BASED CARE PROGRAM

CHRONIC OBSTRUCTIVE

PULMONARY DISEASE

PATIENT PATHWAY

NOTE: Grey Bruce Health Network is starting to use computer patient charts to record the care that has been given to you

by hospital staff. Using the computer lets us have quick access to your patient chart and keeps us up-to-date with important

information about your health. This helps us to give you the best care where and when you need it. This Electronic Patient

Record is part of the Ontario wide plan to make your Electronic Health Record complete with records from other health

care people like your Family Physician, etc.

Your personal health information is password protected to keep it private and confidential. This allows for each one of your

health care team to see only the information they need to treat you.

Updated May 2013 Review May 2016

© 2006-2013 Grey Bruce Health Network

PROCESS

PATIENT RESPONSIBILITIES

ASSESSMENT

TESTS

MEDICATIONS

NOTES:

ADMISSION

It is important that all patients with COPD understand how they can help

themselves get better and how they can stay healthy for as long as

possible. This can be done by learning about your disease. The hospital

staff will help you understand the information you are given and if you do

not understand some of it, or have questions, please ask the people

providing your care.

Your temperature, pulse, breathing and blood pressure will be checked.

Different healthcare providers will listen to your chest and assess your

breathing. They will ask you questions about your shortness of breath and

provide you with a scale to help you rate it.

You should let the nurse know if you are not making as much urine as you

normally do at home, especially when you are trying to drink more while

in hospital.

You will have some blood tests done and a chest x-ray taken.

Swabbing of the nose and anus on admission is necessary on all patients

admitted to the hospital. You may need to be put in isolation until the

results of those tests are known. This is a precaution to protect all of the

other patients as well as yourself.

Drugs will be given to you as ordered by your doctor. These will probably

include antibiotic(s) and medication to help with your breathing.

Once you have been placed on the right medication and you are ready to

go home, a complete list of your medications will be given to you as well

as a prescription. The medication may need to be adjusted from time to

time until the right combination is found.

PROCESS

TREATMENTS

NUTRITION

ACTIVITY

EDUCATION

DISCHARGE

PLANNING

NOTES:

ADMISSION

You will be given oxygen through a face mask or small prongs in your

nose if necessary.

Medications in the form of a mist are sometimes used with a mask to help

with your breathing.

You may eat or drink as you like, unless you require a special diet.

It is important that you drink a lot of fluids.

You will be encouraged to move as much as possible. Staff will assist you

as needed.

Reading your printed material given, asking questions about things you

don't understand, and communicating with your healthcare providers is the

key to getting you better and home as quickly and safely as possible.

A team of people are already working on getting you ready for home.

Please let your healthcare provider know if you have been having some

problems doing some of the activities at home.

Maybe we will be able to help you with some of those things to make it

easier for you to breathe once you arrive there.

PROCESS

PATIENT

OUTCOMES

ASSESSMENT

TESTS

MEDICATIONS

TREATMENTS

NUTRITION

ACTIVITY

NOTES:

PHASE 1 (AT ABOUT 2 DAYS)

You are now starting to breathe easier.

You should have no fever.

Your temperature, pulse, breathing and blood pressure will be checked

less often, but still when you need it.


breathing and continue to ask you about the breathing scale and how short

of breath you feel.

You should be doing to the bathroom normally.

There may be more tests depending on how you are doing.

You will continue taking drugs to help you breathe.

The medication with the mist may be changed to a puffer with a "spacer"

attached, if it hasn't already.

You may still have the medication in the mist, but you will need to let the

nurses know that you require it BEFORE you are very short of breath.

If you have a puffer that is kept at your bedside, you need to let the nurse

know EVERY TIME you use it and how much you use.

You will continue to receive oxygen if necessary.

Your oxygen needs should be approaching what is normal for you when

you are well at home.

You will be encouraged to drink extra fluids.

You will be encouraged to sit in a chair and walk short distances today.

Staff will assist you as needed.

This is very important to the speed of your recovery.

DO NOT do exercises that make you very short of breath so that you feel

like you cannot recover easily.

PROCESS

EDUCATION

DISCHARGE

PLANNING

NOTES:

PHASE 1 (AT ABOUT 2 DAYS)

Education is very important in helping you manage your disease and stay

healthy longer.

You will be given a booklet that will help you to understand what COPD

is and what support is available to help.

The folder you have been given is yours to keep. It has basic information

about your disease. more information can be given to you if you want to

learn more about certain subjects.

You can also find a lot of information on The Lung Association website at

www.on.lung.ca and look under the tab "Lung Health".

You are to take this folder with you to your healthcare practitioner when

you see them after discharge and they will provide you with additional

education when there.

A Community Care Access Centre Case Manager may talk with you, with

your permission, if needed, to plan for your discharge from hospital.

PROCESS

PATIENT

OUTCOMES

ASSESSMENT

TESTS

MEDICATIONS

TREATMENTS

NUTRITION

ACTIVITY

EDUCATION

DISCHARGE

PLANNING

NOTES:

PHASE 2 (AT ABOUT 2 - 5 DAYS)

You are now preparing for discharge.

Your breathing should be back to normal and you should be off oxygen by

the time you are discharged, if you normally do not use oxygen at home.

If you used oxygen at home before admission you should have someone

bring your portable tank to be available for your day of discharge.

Your temperature, pulse, breathing and blood pressure will be checked.


breathing.

You may have some blood work done.

You will continue taking drugs to help your breathing. Let the nurse know

if you are having difficulty breathing.

Your need for oxygen will be reassessed.

Continue deep breathing and coughing exercises.

You should continue to drink extra fluids.

You will be encouraged to continue moving and walking as much as

possible, increasing your activity level each day in preparation for

returning home.

Different healthcare providers will review the booklet on COPD with you.

You will receive instructions to help you prepare for discharge, including

reasons to call your doctor.

A pharmacist/nurse may see you if the drugs you took at home before

coming to the hospital have changed a great deal.

A Community Care Access Centre Case Manager may talk with you, with

your permission, if needed.

You may be discharged if your breathing is improving.

PROCESS

PATIENT

OUTCOMES

ASSESSMENT

TESTS

MEDICATIONS

TREATMENTS

NUTRITION

ACTIVITY

EDUCATION

DISCHARGE

PLANNING

NOTES:

DISCHARGE CRITERIA

You should now understand what to do when you leave the hospital to

care for your COPD. You should be moving and walking like you did

before you had this attack.

You may be referred for oxygen at your home if necessary.

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.

You will be given a prescription when discharged. Please take them

exactly as ordered by your doctor. The nurse will go over your

medications with you and highlight any changes that might have been

made to your routine medications. You should also go over your entire list

of medications with your pharmacist when you get the prescription filled.

It is a good idea to always use the same pharmacy so they have your

complete records in case there are questions you have.

Continue to drink a lot of water and eat a balanced diet.

Continuing to be mobile and active is very important to your disease.

Being more mobile helps to improve and maintain your lung function.

A nurse will review your discharge instructions with you and your family.

If you have been instructed to continue to take antibiotics or breathing

medication at home, you will be given a discharge prescription.

Remember not to do activities that leave you breathless and feeling unable

to recover.

chronic obstructive pulmonary disease … · clinical pathway checklist process ... if patient co 2...

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