hci international medical centre - qi hub care... · patient / relative / gp referral letter / gp...

1

Golden Jubilee National Hospital

Total Knee Replacement – Side: __________

Patient label

Confidential

Pre assessment date _________________________________________

Consultant Pre assessment nurse

Provisional date of admission Actual date of admission

Provisional date of surgery Actual date of surgery

Expected date of discharge Occupational Therapist

Physiotherapist Attended pre-op talk Yes No

Alerts / allergies Comments

1. _________________________

2. _________________________

3. _________________________

4. _________________________

5. _________________________

6. _________________________

2

Total Knee Replacement Integrated Care Pathway

Date: ______/______/______

Affix addressograph label or complete:

Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

All staff

Please SIGN, PRINT and INITIAL below when you make your first written entry on the pathway

Print Sign Designation Initial

3


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Patient’s address: __________________________ Tel No:________________ Postcode: __________ Date of birth: _____/_____/_____ Age: ________ Marital status: ____________________________ Label details checked and correct Patient likes to be called: _________________ Occupation: ___________________________ Religion: _____________________________

GP name: _______________________________ GP address: _____________________________ Postcode:___________ Tel no: _______________

Next of Kin: ______________________________ Relationship: _____________________________ Address: ________________________________ _____________________ Postcode: __________ Telephone: ______________________________

Height: ______________ Weight: ___________ BMI: ____________ Oxford score : ____________

Blood pressure: ____________________________ Temperature: ______________________________ Pulse: ____________________________________ O2 saturation: _____________________________

Diabetic: Yes No If Yes BM: __________________

Date L.M.P. _____ / _____ / _____ Pregnancy test required? Yes No Result: __________________________________

Who will collect patient after surgery? Relative / friend May require transport

4


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Lives: Alone: Is patient independent? With healthy partner / family?: With elderly / infirm partner?: Does patient look after someone?: Yes No If yes, number of dependants: __________ Who is caring for dependant whilst patient is in hospital? ________________________________ If yes email discharge team

Does the patient have: Nursing home care: Residential care: Community nursing services: Home care services: Personal care: Meal preparation: If yes, which meals: Breakfast Lunch Dinner Shopping Housework Tuck in

Personal hygiene: Independent: Yes No If no, what assistance is required? Can dress independently: Yes No If no, what assistance is required?

Nutrition: No special requirements:

Therapeutic diet (state) ______________________

Cultural / ethnic diet (state) ___________________ Email dietician if celiac / peanut allergy or low BMI

Mobility: Independent Stick(s) Frame Wheelchair Hoist

Communication: Communicates effectively Impaired speech Visual aids Learning difficulties Cognitive issues (If yes to any, email clinical areas).

Primary language: Interpreter required Yes No Language: ________________________________ (If yes, email clinical areas).

Hearing; Normal Dull Hearing aid L R Bilateral Vision: Glasses Contact lenses Registered blind Eye disease

Emotional state: Alert / orientated Confused Mildly anxious Highly anxious History of depression History of anxiety

Falls questions How many falls have you had in the last six months? _________________________________ (If has had falls, email clinical areas).

5


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Medication on admission

Date of pre-admission clinic: ____________________ Date of admission: _______________ Allergy: NKDA Latex Yes No Metal: ________________ Reaction: ______________ Drug or other: ___________________________ Reaction: ______________________________________ Drug or other: ___________________________ Reaction: ______________________________________ Drug or other: ___________________________ Reaction: ______________________________________ Drug or other: ___________________________ Reaction: ______________________________________ Medication details to be filled by doctor, nurse or pharmacist Source of history (please circle) Patient / relative / GP referral letter / GP practice / old notes / Nursing home kardex / patient / list patients own drugs / Community Pharmacy _________________________________

Admission medication Medication change (please tick)

Freq Name Dose 8am 12pm 6pm 10pm PRN

Hold Stop Comments (if medication held or stopped

Any herbal / over the counter medicines

Any Further Action required? Yes No E.g. ring GP in morning as medication unclear, check dose with relative

Comments

Mdication history completed by: _____________________ Designation _____________ Date/time ____________

Doctors Signature _________________________________ Date/time _______________________

6


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Pre-assessment details and medication confirmed

Investigations reviewed

General external Well / pale / cyanosed / clubbed / jaundiced / kachetic

CVS Pulse BP JVP

Apex Beat

Heart Sounds Oedema

RS Respiratory Rate

Trachea

Chest Expansion

BS (Breath Sounds)

SATS % R L

Abdomen

CNS / Locomotor Pulses Bruit

Assessing Doctor / Staff Nurse: Print Name:

Signature:

Date: Time: Designation:

·

7


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Past medical history Previous surgery / dates

Year

Year Surgery

Any recent hospital admit

Awaiting any tests / investigations

Any problems with anaesthetic Yes No Details:

Any family member with Yes No Details: anaesthetic problems?

Diagram of Mallampati’s score Class 1 – 4 Class ___________ Full range of neck movement Yes No Comments:

Joint / spinal problems Yes No Comments:

Dentition: Yes No Comments:

Any dental problems Yes No Details: Date last dental appointment:

8


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

All staff

Cardiac / respiratory Yes No Angina on exertion or rest? (use of GTN) Hypertension? Myocardial infarction? Year _______ Pacemaker (inform cardiology of details) Cardiac investigations? (ETT, Echo, Angiogram etc) Year _______ Heart murmur / rheumatic fever? Palpitations or arrhythmia? Ankle swelling or oedema? Left Right Bilateral *****Symptoms of breathlessness at Rest or Exertion (please circle)

Maximum equivalent activity (MET)

Eating/ Walk around Hill incline 2 flights of Jogging Dressing the house stairs 1 2 3 4 5 6 7 8 9 10

Take a Walk on Brisk walk Brisk swim shower level ground

Estimated METS score _______________ What prevents further activity?

Yes No Comments Angina

Arthritis or leg pain

Other (?weight) Yes No

*****Lie flat without getting breathless? No. of pillows required ____ *****Do you have sleep Apneoa (If concerned re new symptoms refer to Anaesthetist)

Asthma? / COPD? Peak flow 1 _______ 2 _______ 3 ________ Present or recent chest infection? Productive cough History of Tuberculosis? ******Deep Vein Thrombosis (DVT) or Pulmonary Embolus (PE)?

9


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Central nervous system Yes No

****Epilepsy / seizures

Cerebrovascular accident (CVA) or Transient Ischaemic Attack (TIA)?

Fainting / dizzy spells?

Gastrointestinal Yes No

*****Heartburn / indigestion / gastric reflux? / hiatus hernia

Nausea or vomiting? Recent weight loss?

*****Liver problems / jaundice / hepatitis

Bowel disorders?

Renal / genito-urinary / musculo-skeletal / other Yes No

Kidney disease?

Urinary problems?

Prostate problems / investigations? Specify: __________________________________________________

Muscle disease or progressive weakness?

*****Diabetes Type: ____________________________________

Thyroid problems? Hyperthyroidish Hypothyroidish

Skin conditions Specify: __________________________________________________

Any other serious illnesses (please list)

10


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Haematological Yes No

Anaemia

Haemophilia / blood disorders

Excessive bruising

Blood transfusion Year __________

Does patient smoke Yes No How many:

Does patient drink alcohol Yes No Number of units:

Does patient take recreational drugs Yes No Comments:

Investigations

Joint x-ray taken Yes No Chest x-ray required Yes No

If x-rays are less than 6 months old, do not repeat unless requested by Consultant. Blood samples taken (please circle)

Group and save / crossmatch Yes No Chemistry profile Yes No Full blood count Yes No Coagulation screen Yes No INR Yes No Blood glucose level Yes No Other? ___________________________________________________________________

12-lead ECG taken? Yes No All patients over 45 years of age should have a 12-lead taken. If “yes”, please give details below. Urinalysis / MSSU

Specimen sent? Yes No Attach printout

11


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

GJNH Risk Assessment for Thromboembolic Disease

Risk factors

• Previous DVT

• Previous PE

• Family history of VTE

• BMI >30

• Age >60

• Current malignancy

• Significant medical co morbidities

• HRT / contraception

Bleeding risk

• Existing anticoagulant / antiplatelet therapy

• Severe liver disease

• Haemophilia or other bleeding disorder

• Thrombocytopaenia

Type of surgery

• Hand or foot surgery

• Arthroscopic knee surgery

• Primary TKR / THR

• Bilateral TKR / THR

• Revision TKR / THR

Risk Assessment

VTE Bleeding risk

• Low • Low

• Medium • High

• High

• Very high

VTE prophylaxis recommended: (refer to current orthopaedic department guidelines)

Name Signature Date

12


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Infection Control admission assessment

Complete CJD risk assessment if not completed at pre assessment Have you ever been notified that you are at increased risk of CJD or v CJD for public health purposes?

Annex 1 Brain High Spinal cord High Dura mater High Cranial nerves High Cranial ganglia High Posterior eye High Pituitary gland High

When taking a dry swab ensure it has been rubbed over area 10-20 times covering all surfaces of swab.

Infection assessment Admission MRSA screen taken? Yes No Does the patient have any wounds or invasive devices? Yes No

Nose Groin Perineum Wound Device Site ……………..….. Type …………..….……. If IV indicate location ____________________

Does the patient have any signs of infection? Yes No Take swab or urine sample if yes.

Wound Device Other Urine

Does the patient have an exfoliating skin condition? Yes No Take swab from one broken or inflamed area if yes and document skin condition.

Site

Has the patient been on antibiotics within the last 12 weeks? Yes No Not known

If yes, specify antibiotic name and reason for use. ________________________________________________________________________________

Has the patient had diarrhoea and / or vomiting within the last 48 hours? Yes No

If yes, please specify Obtain sample Isolate Inform Infection Control

Has the patient had any previous hospital admissions in the past 12 weeks? Yes No

If yes, please specify ________________________________________________________________________________

Response No

Surgery or endoscopy should proceed using normal infection control procedures unless the procedure is likely to lead to contact with high risk tissue. (see annex 1)

Yes Contact the Prevention and Control of infection team.

Unable to response Contact the Prevention and Control of infection team.

13


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Patient confirms all information obtained in ICP at pre assessment Yes No

Have you had a flu vaccination this season YES NO

Information on Anaesthetic given to patient DVD re exercises given to patient Discharge/ Arthroplasty follow up Information given to patient Patient Guide given to patient

Patient assessment continued

Comments

Date completed: RN signature:

14

Total Hip Replacement Integrated Care Pathway

Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Patient assessment continued

Comments

Date completed: RN signature:

15


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Doctors notes

Comments

16


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Doctors notes

Comments

17


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Doctors notes

Comments

18


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Doctors notes

Comments

19


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Occupational Therapy pre-operative assessment: R/L TKR

O.T. introduced self Explained role of O.T.

Consent to treatment Consent to share information

Social History:

Roles: Working Retired Carer Other…………………………………

Living group: Alone Partner/ spouse Other…………………………………

Housing: Owner occupier Tenant of ………………………………………………

Accommodation House Number of levels ………………………………………………

Bungalow

Flat Position ………………………………………………

External access: …….. stairs, rail right side ascending left side ascending bilateral Nil

Internal access: …….. stairs, rail right side ascending left side ascending bilateral Nil

Internal stairs: …….. stairs, rail right side ascending left side ascending bilateral Nil

Room layout: Living area Level Up Down

Kitchen Level Up Down

Bedroom Level Up Down

Bathroom Level Up Down

Home situation prior to admission:

Seating …….. inches Bed …….. inches Toilet …….. inches

Bathing facilities: ……………………………………………………………………………………………………

Domestic ADL: Independent Family assist Home Help ………………… per week

Comments ……………………………………………………………………………………………………

Support available at home: ……………………………………………………………………………………………

20


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Occupational Therapy pre-operative assessment: R/L TKR (cont’d)

Post discharge support required with:

TEDs Personal care Meal prep Domestic tasks N/A

Other ……………………………………………………………………………………………………

Joint replacement discussed in relation to function and activities of daily living

Recommended height ………………..inches

Ward equipment: R.T.S ………inches L.H.S.H H.H Other ……………… Equipment required for discharge: Not applicable

Equipment provider: ……………………………………………………………………………………………

Access arrangements: …………………………………………………………………………………………

Treatment Plan: Order equipment…………………………………………………………

Functional assessment…………………………………………………..

Other ……………………………………………………………………

Time: ………………… Signature:……………………………………(Occupational Therapist)

Date assessment completed: …………………

To be completed by Rehab Assistant

Patient admitted to ward Equipment insitu at home All above information remains accurate Signature: _________________________________

Equipment requested: please supply X

Helping Hand (H.H) Perch stool with arms (seat height)

Long Handled Shoe Horn. (L.H.S.H.) Trolley (handle height)

Sock Aid / Tights Aid Chair (seat height)

Raised Toilet Seat (size) (R.T.S) Chair raiser (size) (base) raised by: __________

Toilet frame (seat height) Cushion

Toilet frame (no seat)

Showerstool with arms (seat height) Bed raiser (size) (base)

Showerboard

To facilitate transfer ……….. leg leading Grab rails:

Other:

21


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Discharge checklist (commence on admission)

Expected Date of Discharge (EDD): ____/____/____ EDD discussed with patient: Yes No

Transport Signature

Own transport Approximate time for collection: ___________

GJNH Hospital transport Time for collection: ________________

Scottish Ambulance Service 1 man 2 man

Time for collection: ________________ Escort required: Yes No If Yes details:__________________________

Discharge medication (TTO)

TTO prescription complete and sent to pharmacy

Yes No

Medication explained and given to patient

Yes No

Referrals/ appointments made

Arthroplasty appt made Yes No

Social services aware Yes No N/A If Yes see next page

Practice Nurse letter complete Yes No N/A

(If required) District nurse contacted Yes No N/A

GP letter complete Yes No

Anticoagulation appt made if needed:

Yes No If Yes date of appt: ___________________

Other

Discharged from Physio Yes No

Discharged from OT Yes No

Valuables returned Yes No N/A

All invasive lines removed Yes No

Relatives aware of discharge Yes No

22


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Social Services requirements

Local Authority Contact Telephone Number Named Contact Direct Dial Number Home care requirements

Yes No Social Services

Family / friends

Signature

Assistance to get washed Assistance to get dressed Assistance with TED stockings Meal preparation Breakfast Lunch Evening Meal Drinks Meals on wheels Shopping Food train (Dumfries & Galloway)

Housework Laundry Emptying commode Tuck in service Prompt with medication Collection of medication Carers Assessment Community Care Assessment Community Alarm Key Safe Date and time care will start:

Morning Lunchtime Tea time Tuck in

Exact time cannot be given

Comments:

23


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Nutritional Assessment – admission day

Dietary requirements Yes No Comments Therapeutic diet e.g. food allergy, diabetes

Type of diet: Dietitian referral if appropriate

Diet preferences e.g. cultural, religion, ethnic

Type of diet:

Regular vitamin and/or mineral supplement

List:

Feeding aids required: Crockery Cutlery Drinking utensil

Contact Catering department

Food and Fluid Pattern Appetite Good Small Poor Comments: Drink Preferences eg tea, squash ………………………………. Cups/glasses per day ______

Eating and/or meal preferences Three meals/day Two meals + a snack One meal + two snacks snack meals only One meal/day Other please specify…………………... Comments:

MUST Score Body Mass Index (BMI) Greater than 20 - Score 0 18.5 – 20 - Score 1 Less than 18.5 - Score 2

Unplanned Weight Loss over past 3-6 months Less than 5% - Score 0 5 – 10% - Score 1 More than 10% - Score 2

Acute Illness Will patient have no/minimal diet for next 5 days? Yes Score 2 No, can eat normal/light diet – Score 0

Total MUST Score: _______________ If score 1 then monitor and record in care plan If score 2 or more, refer to dietitian and record in care plan

Signature and date: Dietician review: Signed: ______________________________________ Date: ______________

24


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Pharmacy admission day

Activity Comments

Medication history taken Yes No

Patients own medication assessed Yes No

Kardex reviewed Yes No

Pharmacy care plan completed Yes No

Time:

Pharmacist’s Signature:

25


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Admission day

Admission procedures checklist:

Consent Leg marked ECG XRAY Bloods MRSA TEDS Size: _____ Bilateral/Revision patients – Group & Save obtained

No. Nursing care plan Comments (please state time at any comment)

1 ID band correct and in situ Yes No

2 Red band insitu if patient has allergies Yes No N/A

3 Infection control issues, specify: Yes No

4 MUST score documented Yes No

5 Waterlow score documented Yes No

6 Skin intact Yes No

7 Falls risk assessment carried out Yes No

8 VTE risk assessment carried out Yes No

9 Seen by anaesthetist and premed prescribed

Yes No

10 Observations recorded on MEWS chart and within normal range. MEWS score recorded

Yes No

11 Patient fully understands all information provided including showering/fasting instructions

Yes No

12 Self caring Yes No

13 Mobile independently Yes No

14 Valuables given to security Yes No N/A

15 Discharge plan commenced (see pg 21) Yes No

16 Check mode of transport for discharge Yes No

17 If patient has social services pre-op they are aware of admission

Yes No

Registered Nurse Signature Day Shift: _____________________

Registered Nurse Signature Night Shift: _____________________

26


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Admission day

Time Activity number

Notes Signature

27


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Pre-op checklist

Description Yes No

1. ID Band correct

2. Patient has an allergy

3. Consent signed and in notes

4. Leg marked

5. Prosthesis removed

6. Artificial joint or implant

7. Jewellery removed/taped

8. Hairpins removed

9. Nail polish removed

10. Make-up removed

11. Dentures removed

12. Caps/crowns Top Front Bottom Front Top Right Bottom Right Top Left Bottom Left

13. Hearing aid in place

14. Pre-medication @ ___________ hours

15. Last food @ __________ hours Last drink @ _________ hours

16. If a diabetic, last blood glucose = _______ mmols/L @ ________ hours

17. Since date of LMP could you be pregnant Yes No N/A

18. Observations in patient’s normal range

19. Patient has had a hibiscrub shower using disposable cloths

20. Laboratory results available Yes No Not taken N/A 21. Comments:

Completed on ward by: Checked in pre op by:

28


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Anaesthetics perioperative record

Fluids Hartmans solution

mls

Gelofusine

mls

Estimated blood loss

mls

Other

mls

Other

mls

Comments:

Infiltration Yes No Volume ……………………………. Route of administration………………………………………………….. Skin closure Site 1. …………………………… Dressing…………………………………… Absorbable / Non absorbable / Staples Site 2. …………………………… Dressing……………………………………. Absorbable / Non absorbable / Staples / Sternal wires Other sites………………………………… Drain Yes No Number Type…………………. Secured with ………………… Opened in theatre Open in PACU Drain opening time ………………………………………………. Drainage on leaving theatre ………………………………………

29


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Implant labels and tracability labels

Specific post operative instructions for PACU/wards

Scrub Nurse Signature

Circulating Nurse Signature

30


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Theatre day

No. Nursing care plan

Comments (please state time at any comment)




4 Fluid balance commenced Yes No

5 TED stockings/ AV boots worn Yes No

6 Baseline observations recorded on return to ward then protocol followed according to analgesic regime. MEWS recorded

Yes No

7 Signs of shock Yes No

8 Has passed urine within 8 hours of theatre. If not fluid balance protocol followed

Yes No

9 Wound site satisfactory Yes No

10 C.S.M. satisfactory Yes No

11 Patient indicates adequate pain control Yes No

12 Nausea or vomiting Yes No

13 Tolerating diet and fluids Yes No

14 P.V.C bundle commenced and continued 8 hourly

Yes No


16 P.A.C. carried out 2 – 4 hourly and documentation completed

Yes No

17 Skin intact Yes No

18 Up to sit once mobility assessment carried out by Physio or appropriately trained nurse

Yes No

19 Manual handling techniques adhered to when moving patient

Yes No

20 Patient hygiene needs met Yes No

21 Patient fully understands all information provided

Yes No

22 Nurse call buzzer within reach at all times Yes No

23 Discharge plan continued (see pg 21) Yes No

Registered Nurse Signature Day Shift ____________________

Registered Nurse Signature Night Shift ____________________

31


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Theatre day

Time Activity

Number Notes Signature

32

Manual handling risk assessment – Theatre day


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Manual handling category Low Medium High 1. Moving in bed

Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required

2. Turning in bed Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required

3.Transferring bed to chair / chair to bed

Self care Yes No If No comments:____________________________________

4.Standing/ mobilising in room


5. Personal hygiene Self care Yes No If No comments:____________________________________

6. Toileting Self care Yes No If No comments:____________________________________

7.Mobilising out with room Self care Yes No If No comments:____________________________________

Additional comments

Signature

Nursing – Day shift Time: ___________ Sign: ____________________

Nursing – Night shift Time:__________ Sign: ______________________

33

Physiotherapy post operative Day 0

AO1/AO2 = assistance of 1/2 person; SLR = straight leg raise, IRQ= inner range quadriceps, ROM = range of movement

On weekend list: Yes No N/A Mobilised with nursing staff


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

1. Physio Patient advised re deep breathing and circulatory exercises Yes No

2. Physio Pre mobility checks: Comments:

Blood Pressure _________________________________________________________

Sensation _________________________________________________________

SLR Non operated side Yes No _________________________ Operated side Yes No _________________________ IRQ Operated side Yes No _________________________

3. Physio Strodex splint required: Yes No Comment:_______________________

4. Physio Bed transfers: assistance required: Supervision MIN MOD MAX AO1 / AO2

5. Physio Transferred bed to chair: Yes No

6. Physio treatment:

Reason not mobilised: 1. Blocked 2. Hypotensive 3. Nausea & vomiting 4. Vasovagal 5. Pain 6. Not eaten 7. Late back ______________________ 8. Poor Proprioception 9. Other ______________________

7. Physio treatment plan: Physiotherapist signature: ______________________________________ Time: _____________

34

Post operative Day 1


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

No. Nursing care plan Comment (please state time at any comment)




4 Fluid balance continues Yes No


6 Vital signs recorded 4 hourly and MEWS score completed

Yes No



9 Patient indicates adequate pain control. Pain score documented

Yes No

10 Wound / Epidural catheter removed Yes No N/A


12 Tolerating fluids and diet Yes No

13 P.V.C bundle continues Yes No


15 P.A.C. carried out and skin intact Yes No

16 Up to sit and mobile as per Physio instructions

Yes No

17 Occupational therapy commenced Yes No



Yes No


21 Discharge plan continues (see pg 21) Yes No

22 TTO ordered Yes No

Registered Nurse signature Day shift: ______________________________

Registered Nurse signature Night shift: _____________________________

35



Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Time Activity Number

Notes Signature

36

Manual handling risk assessment – Post operative Day 1


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:











Additional comments

Signature

Nursing – Day shift Time: ___________ Sign: ____________________

Nursing – Night shift Time:__________ Sign: ______________________

37



On weekend list: Yes No N/A


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

1. Physio Pre mobility checks: Comments: Up POD 0 Blood Pressure ______________________________________________________________ Sensation ______________________________________________________________ SLR Non operated side Yes No ___________________________ Operated side Yes No ___________________________ IRQ Operated side Yes No ___________________________

2. Physio Strodex splint required: Yes No Comment:___________________________

3. Physio Bed transfers: assistance required: Supervision MIN MOD MAX AO1 / AO2

4. Physio Transferred bed to chair: Yes No

5. Physio Extension _________________ Flexion _________________

6. Rehab Assistant: Commenced active exercises: Yes No SQ: _________________________________ IRQ: _________________________________ SLR: _________________________________ ROM: _________________________________

7. Physio treatment AM:

Treatment plan:

8. Physio treatment PM:

Treatment plan:

9. Physio Stair assessment commenced: Yes No Independent on stairs Yes No Further practice required Yes No Comments: ________________________________

10. Physio Discharged from Physio Yes No Out patient Physio required Yes No Comments: _____________________________

AM Physiotherapist signature: __________________________________Time: _______

PM Physiotherapist signature: __________________________________Time: _______

38

Occupational Therapy post operative Day 1

O.T. Intervention today: No intervention required Not appropriate ________________________ O.T. unable to see …………………… No O.T. service available i.e. non working day Occupational Therapy complete: Yes No



Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Personal care / dressing tasks: Not Applicable To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of small aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ………………………………………………………………………………………………………………………………………….. Practice sessions required Yes No

Functional mobility: Assisted Supervised Independent Using: Mobilator Crutches x…... Sticks x …...

Transfer ability: Not Applicable To be assessed Assessment completed Equipment Used Chair: Dependent Assisted Supervised Independent Bed: Dependent Assisted Supervised Independent Toilet: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No

Kitchen assessment, basic tasks: Not Applicable To be assessed Assessment completed Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No

Bathing assessment Not Applicable, advised to strip wash To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of bath aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ………………………………………………………………………………………………………………………………………….. Practice sessions required Yes No Referral made for post discharge provision of equipment

Essential Equipment Insitu: Yes No N/A

Outstanding Issues: Comments:

39


R.T.S, Raised toilet seat L.H.S.H, Long handled shoe horn H.H., helping hand


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Activity:

Dressing Transfers Kitchen Bathing Other: …………………………

Level of ability: Dependent Assisted Supervised Independent

Equipment used:

Comment:

Further practice sessions required: Yes No

Completed by: Designation: Date:

Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:



40


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


No. Nursing care plan Comment (please state time at any

comment)




4 Fluid balance discontinued Yes No



Yes No




Yes No


11 Check x-ray carried out Yes No

12 FBC and U&E’s obtained Yes No

13 Venflon removed Yes No



16 Mobile as per Physio instructions Yes No

17 Occupational therapy continues Yes No



Yes No




Registered Nurse signature Day shift: _____________________

Registered Nurse signature Night shift: _____________________

41


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


Time Activity


42


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:












Additional comments

Signature

Nursing – day shift Time: ___________ Sign: ____________________

Nursing – night shift Time:__________ Sign: ______________________

43


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:




1. Physio Strodex splint required: Yes No

2. Physio Mobility with walking aid: Commenced gait re-ed with sticks / crutches Yes No

Gait pattern or comments: ________________________________________________________________

_____________________________________________________________________________________


4. Quadriceps control: Comments: SQ: ____________________________________________________________________ IRQ: ____________________________________________________________________ SLR: ____________________________________________________________________

5. Rehab Assistant notes: Commenced active exercises: Yes No

SQ: _______________________________ IRQ: _______________________________ SLR: _______________________________ ROM: _______________________________


Treatment plan:


Treatment plan:





44





Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:



Transfer ability: Not Applicable To be assessed Assessment completed Equipment Used Chair: Dependent Assisted Supervised Independent Bed: Dependent Assisted Supervised Independent Toilet: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ………………………………………………………………………………………………………………………………………….. Practice sessions required Yes No

Kitchen assessment, basic tasks: Not Applicable To be assessed Assessment completed Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ………………………………………………………………………………………………………………………………………….. Practice sessions required Yes No

Bathing assessment Not Applicable, advised to strip wash To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of bath aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ……………………………………………………………………………………………………………………………………………Practice sessions required Yes No Referral made for post discharge provision of equipment


Outstanding Issues:

45


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:




46


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:








Yes No




Yes No




12 Occupational therapy continues Yes No



Yes No






47


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:



Notes Signature

48


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:












Additional comments

Signature

Nursing – day shift Time: ___________ Sign: ____________________


49


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:




1. Physio Independent with all transfers: Yes No

2. Physio Independently mobile with elbow crutches / sticks Yes No


4. Physio Quadriceps control

5. Rehab Assistant notes:


Treatment plan:


Treatment plan:





50

Occupational Therapy post operative Day 3 Personal care / dressing tasks: Not Applicable To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of small aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ………………………………………………………………………………………………………………………………………….. Practice sessions required Yes No


Transfer ability: Not Applicable To be assessed Assessment completed Equipment Used Chair: Dependent Assisted Supervised Independent Bed: Dependent Assisted Supervised Independent Toilet: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ………………………………………………………………………………………………………………………………………….. Practice sessions required Yes No

Kitchen assessment, basic tasks: Not Applicable To be assessed Assessment completed Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No



Outstanding Issues:




Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

51


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:




52


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:



comment)




4 TED stockings worn Yes No


Yes No




Yes No




12 Patient independent with hygiene Yes No


Yes No


15 Discharged from Physiotherapist Yes No

16 Discharged from Occupational Therapist Yes No

17 Discharge plan complete (see pg 21) Yes No


Registered Nurse Signature Day Shift: _____________________

Registered Nurse Signature Night Shift: _____________________

53


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:



Notes Signature

54


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


Is patient independent in all activities of daily living: Yes No If no, continue to complete rest of risk assessment Manual handling category Low Medium High 1. Moving in bed





4.Standing/ mobilising in room Self care Yes No If No comments:____________________________________




Additional comments

Signature

Nursing – day shift Time: ___________ Sign: ___________________


55


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:










Treatment plan:


Treatment plan:





56




Transfer ability: Not Applicable To be assessed Assessment completed Equipment Used Chair: Dependent Assisted Supervised Independent Bed: Dependent Assisted Supervised Independent Toilet: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ……………………………………………………………………………………………………………………………………………Practice sessions required Yes No

Kitchen assessment, basic tasks: Not Applicable To be assessed Assessment completed Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ……………………………………………………………………………………………………………………………………………Practice sessions required Yes No



Outstanding Issues:




Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

57


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:




58


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:








Yes No




Yes No







Yes No








59


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


Nutritional Re-assessment:

Diet/Fluid requirements Comments Oral Fluid Intake Good, 2 litres/day or more ٱNormal, 1.5 –2 litres/day ٱPoor, 1 litre/day or less ٱ

Include action if poor intake.

Vitamin/ mineral Supplement Prescribed.

Yes No List:

Feeding aids required: Crockery Cutlery Drinking Utensil

Yes No Catering department aware

Food Pattern Appetite Normal (i.e. same/better than at home) Reduced but improving Poor Comments:

Dietary supplements prescribed Milk Shake Style Fruit Juice Style Other Name………………...…………… Supply required for home – Yes No

Updated MUST score Body Mass Index (BMI) Greater than 20 - Score 0 18.5 – 20 - Score 1 Less than 18.5 - Score 2

Unplanned weight loss Less than 5% - Score 0 5 – 10%% - Score 1 More than 10% - Score 2

Acute illness Has the patient had minimal/poor diet for last 5 days? Yes – Score 2 No, eating normally – Score 0

Total MUST score: _______________ If score 1 then monitor & record in care plan If score 2 or more, refer to dietitian

Signed: Date: Dietitian’s review: Diet advice for home GP Letter

Signed: Date:

60


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


Time Activity


61


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:











Additional comments

Signature



62


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:










Treatment plan:


Treatment plan:





63


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


Personal care / dressing tasks: Not Applicable To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of small aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ……………………………………………………………………………………………………………………………………………Practice sessions required Yes No






Outstanding Issues:



64


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:




65


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:



comment)


2 Red band in situ if patient has allergies Yes No N/A




Yes No




Yes No







Yes No








66


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:



Notes Signature

67


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:











Additional comments

Signature



68


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:










Treatment plan:


Treatment plan:





69


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


Personal care / dressing tasks: Not Applicable To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of small aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ……………………………………………………………………………………………………………………………………………Practice sessions required Yes No






Outstanding Issues:



70


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:



Activity:



Equipment used:

Comment:




71


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Wound assessment chart

Site Date

Time

Score

Time

Score

Time

Score

Time

Score

0 = Dressing dry & intact; 1 = Small strike through; 2 = Moderate strike through; 3 = Large strike through; 4 = Dressing r renewed

Urinary catheterisation Inserted Enter date

Removed Enter date

Catheter type: __________________ Size: ____________ Balloon volume: ________mls Lot No: _______________

72

Continuation sheet


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:

Date Time Notes Signature

73

Continuation sheet


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


74

Continuation sheet


Date: ______/______/______


Patient name:

Hospital number:

DOB: _____/_____/_____ Age:


hci international medical centre - qi hub care... · patient / relative / gp referral letter / gp...

Documents