Acute Stroke Care Pathway - Galway EM
ACUTE STROKE
INTEGRATED CARE PATHWAY
Procedure for the admission of patients to the Acute Stroke Service
1. All patients with acute stroke not requiring ITU/HDU/tertiary referral should be transferred to the Acute Stroke Unit (ASU) as soon as possible following admission to ED.
2. Please immediately inform the Nurse in Charge of the ASU (St Enda’s 4435/4445) of any patient being admitted with stroke.
3. If no bed is immediately available the patient will be listed for the next available ASU bed.
4. All patients with stroke will be initially admitted under the on-call General Physician. On the next working morning (ie non weekend/public holiday) any patient with stroke should be handed over directly to the designated Stroke Consultant accepting referrals for that day. The Nurse in Charge of the Acute Stroke Unit will have the name of this Consultant.
5. The responsibility for care of the patient remains with admitting team until formally accepted by the Stroke Consultant.
6. Urgent advice on the care of a patient with Stroke can be obtained on a 24/7 basis by contacting the Stroke Consultant on call for Thrombolysis (via switch) on that day.
NB: It is the responsibility of the admitting team to formally hand over the patient’s care to the designated Stroke Consultant on the next ordinary working day. The name of this Consultant will be available from the Nurse in Charge of the ASU.
Advice Available From: Acute Stroke Unit Nurse-in-Charge (St Enda’s 4435/4445), Medical SpR (via switch), Stroke Consultant (via switch).
This document must be filed in the main body of the patient’s case notes in chronological order on or before discharge.
Medical Acute Stroke Admission Proforma
|Name & Bleep of Doctor: |Time & Date of assessment: |
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|Date & time of onset of symptoms (if witnessed or patient able to give history): _______________ |
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|or date & time last seen or known to be well if unwitnessed or patient unable to give history: __________ |
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|Presenting Complaint: |
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|History Of Presenting Complaint: |
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|Past Medical/Surgical History: |
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|Stroke Risk Factors: |
|Stroke Risk Factors |
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|Atrial Fibrillation |
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|Hypertension |
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|IHD |
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|Diabetes Mellitus |
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|Hyperlipidemia |
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|Peripheral Arterial Disease |
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|Cardiac Failure |
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|Family History of stroke |
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|Previous TIA/Stroke |
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|Smoker |
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|Pack Years: ________ |
|1 Pack year = 20 cigarettes for a year |
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|Alcohol units per week __________ |
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|Social history (including pre-morbid cognition/function/driving) |
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|Pre-Morbid Cognition: |
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|Pre-Morbid Function: |
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|Lives Alone: Yes No |
|(Pre-morbid functional status) |
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|Other Issues: |
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|Medication on admission: |
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|Allergies/Sensitivities: |
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|General Examination (1) |General Examination (2) |
|Hands: |Temp oC |Pulse: /min |
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|Head, Neck, ENT: | | |
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|Skin: | | |
| |Sp02 % |BP: mmHg |
| |RR: /min |BM: |
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| |Weight: Kg |Urinalysis: |
|Neurological Examination |
| Right Left Cranial Nerves |
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|Power; Arm: Prox Distal Arm: Prox Distal I: |
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|Leg: Prox Distal Leg: Prox Distal II: |
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|Reflexes Arm: Arm: III IV VI: |
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|Leg: Leg: V: |
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|VII: |
|Plantars: |
|VIII: |
|Tone: |
|IX, X: |
|Sensation: |
|XII: |
|Cerebellar: |
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|Hemianopia: |
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|Handedness: Right /Left. Dysarthria. Yes / No. |
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|Dysphasia: Expressive / receptive / both / Neither. |
|Dysphagia. Yes / No. |
|Neglect. Yes / No. |
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|Cardiovascular |Respiratory Examination |Abdominal Examination |
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|Primary Diagnosis |
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|1. TIA: aetiology:________________________________________________________________ |
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|2. Ischemic Stroke: aetiology:_____________________________________________________ |
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|OCSP* Classification:_______________________________________ |
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|3. Intracerebral Haemorrhage: Aetiology_____________________________________________ |
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|4. Subarachnoid Haemorrhage |
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|5. Other: _______________________________________________________________________ |
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|NIHSS Score: __________ |
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|Results of CT Brain: ________________________________________________________________ |
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|Did patient receive thrombolysis? Yes No |
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|If Yes, time of administration: __________________ |
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|If No, reason: ______________________________ |
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|*Oxfordshire Community Stroke Project (Bamford) Classification (cf p 9) |
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|Other Diagnoses |
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|IMMEDIATE MANAGEMENT |
|Commence 4 hourly observations (GCS / Temp / BP / HR / RR / Sats / BMs) |
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|O2 sats < 95%: Maintain saturations >95% with O2 |
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|BM > 11 Commence SC insulin sliding scale (as per glucose Monitoring & Insulin Rx chart) |
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|BM < 4 Correct immediately and monitor blood sugars regularly as per hospital guidelines |
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|Temp > 37.5 Regular Paracetamol PO / PR and look for cause (blood/urine cultures/CXR) |
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|Elevated BP Do NOT acutely lower BP unless discussed with Medical |
|(> 210mmHg) SpR/Stroke Consultant |
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|Low BP Seek immediate senior medical advice and look for cause |
|(< 90mmHg) |
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|Falling GCS Seek immediate senior medical opinion if GCS falls > than 2 points. |
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|INDICATIONS FOR IMMEDIATE CT BRAIN |
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|Contact Radiology SpR on-call (Consultant to Consultant after midnight): |
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|Thrombolysis candidate (Consultant referral only after MIDNIGHT) |
|On anticoagulant treatment with focal neurological symptoms/signs or needs early anticoagulation |
|Known bleeding tendency |
|Depressed conscious level (GCS 3.5 mM & no haemorrhage on CT brain |
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|- Use Pravastatin if patient already stabilised on Warfarin, as Warfarin interacts with Simvastatin |
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|3. For patients considered to be at increased risk of Venous Thromboembolism (VTE) (dependent, prior |
|history of VTE), consider VTE prophylaxis with low-dose unfractionated or low molecular weight |
|heparin unless benefit is outweighed by the risk (eg: large infarct on CT brain or evidence of intracerebral |
|haemorrhage) or other contraindications. We do not recommend Graduated Compression Stockings. |
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|4. Insert IV cannula and commence IV fluids (saline) if clinically indicated |
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CONTINUATION SHEET
MEDICAL MANAGEMENT PLAN
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CONTINUATION SHEET
MEDICAL MANAGEMENT PLAN
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NB:
- 1. PLEASE CONTACT THE NURSE IN CHARGE OF ASU (St Enda’s) EXT 4435/4445 TO ARRANGE FOR ADMISSION TO ASU ASAP AFTER STROKE DIAGNOSIS BEING CONFIRMED
- 2. PLEASE ENSURE THAT PATIENT IS ADMITTED UNDER THE ON CALL GENERAL PHYSICIAN INITIALLY
- 3. PLEASE ENSURE THAT THE PATIENT IS HANDED OVER TO THE ON TAKE STROKE CONSULTANT THE FOLLOWING ORDINARY WORKING (ie non weekend / public holiday) MORNING (THE NURSE IN CHARGE OF ASU WILL INFORM YOU OF WHO THIS IS)
- 4. THE PATIENT REMAINS UNDER THE ADMITTING CONSULTANT UNTIL FORMALLY HANDED OVER TO THE STROKE CONSULTANT
|BAMFORD’S CLINICAL CLASSIFICATION OF STROKE |
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|TACS |All 3 of: |
|Total Anterior Circulation Syndrome |-Unilateral motor deficit of face, arm and leg contralateral to cerebral lesion. |
| |-Homonymous hemianopia contralateral to cerebral lesion. |
| |-New higher cerebral dysfunction (e.g. aphasia, neglect. |
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|PACS |Any 2 of: |
|Partial Anterior Circulation Syndrome |-Unilateral motor deficit of face, arm and leg contralateral to cerebral lesion. |
| |-Homonymous hemianopia contralateral to cerebral lesion. |
| |-New higher cerebral dysfunction (e.g. aphasia, neglect). |
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|POCS |-Ipsilateral cranial nerve (3-12) palsy (single or multiple) with contra-lateral |
|Posterior Circulation Syndrome |motor/sensory deficit. |
| |-Bilateral motor and/ or sensory deficit. |
| |-Disorders of conjugate eye movement. |
| |-Cerebellar dysfunction without ipsilateral long tract signs (as seen in AH). |
| |-Isolated hemianopia or cortical blindness. |
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|LACS |No visual field deficit, no new higher cerebral deficit, no brainstem disturbance, |
|Lacunar Syndromes |no drowsiness |
|- Pure Motor Stroke (most frequent) |Unilateral, pure motor/sensory deficit clearly involving two of three areas (face, |
|- Pure Sensory Stroke |arm and leg) with the whole of one limb being involved. |
|- Sensorimotor Stroke | |
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|- Ataxic Hemiparesis |Including dysarthria clumsy hand syndrome and homolateral ataxia and crural weakness|
ACUTE STROKE UNIT INITIAL MDT ASSESSMENT
|Primary|Name:______________________________ |Patient Marital Status:__________________ |
|detail |Address:____________________________ |Religion:___________________________ |
| |___________________________________ | |
| |___________________________________ |Contact Made with NOK/Key Link: YES NO |
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| |Next of Kin:__________________________ |GP Name and Address:______________________ |
| |NOK Contact:________________________ |_________________________________________ |
| | |_________________________________________ |
| |Key Link Person:_____________________ | |
| |Contact:____________________________ |Phone Number:__________________________ |
|HOME |Lives Alone |Bedroom_______________________________ |
|/SOCAL |Lives with _____________________________ |Bathroom_______________________________ |
|SITUATI|Living Accomodation______________________ |Toilet__________________________________ |
|ON |______________________________________ |Equipment In Place________________________ |
| | |_______________________________________ |
| |Social/Family Supports:__________________ | |
| |______________________________________ |MSW Referral Sent YES NO |
| |______________________________________ |OT Referral Sent YES NO |
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| |Home Environment/Access | |
| |External________________________________ | |
| |______________________________________ | |
| |Internal________________________________ | |
| |Condition Pre- Stroke/Baseline. |Change in condition due to stroke. |
| | |Nursing Intervention. |
|Communi|Communication/Cognition/Perception. |Speech: ______________________________ |
|cation/|Speech: Aphasic Slurred | |
|Cogniti|Non-verbal |Hearing: _______________________________ |
|on/Perc|No difficulty reported Other_____________ | |
|eption.| |Vision: _________________________________ |
| |Hearing: Good Poor | |
| |Hearing Aid: Yes No Present |Memory:________________________________ |
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| |Vision: _______________________________ |Mental state: Alert Confused Drowsy |
| |Glasses: Yes No Present | |
| | |Referred to OT Yes No Date_________ |
| |Memory: No difficulty Mild difficulty | |
| |Moderate difficulty Severe difficulty |Referred to SLT Yes No Date_________ |
| |Baseline Mental state: Alert Confused | |
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|Persona|Skin Intact on admission: YES NO |Skin Intact: YES NO |
|l Care.|Comment _____________________________ |Comment _____________________________ |
| |______________________________________ |______________________________________ |
| | |Waterlow Completed: YES NO |
| |Washing: Ind Ass ×1 Ass×2 |Eye Care: YES NO |
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| |Shower/Bath: Ind Ass ×1 Ass×2 |Oral Hygiene Assessed: YES NO |
| | |Oral Care Indicated: YES NO |
| |Dressing: Ind Ass ×1 Ass×2 | |
| | |Washing: Ind Ass ×1 Ass×2 |
| |Toileting: Ind Ass ×1 Ass×2 |Shower/Bath: Ind Ass ×1 Ass×2 |
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| | |Dressing: Ind Ass ×1 Ass×2 |
| | |Toileting: Ind Ass ×1 Ass×2 |
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| | |Referred to OT: YES NO |
|Eating and|Fluids: Normal Thickened- Grade …… |Initial Swallow screen assessment completed by_________ |
|Drinking. |N.P.O. + PEG/RIG |Time ________________Date____________ |
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| |Diet: Normal Modified………… |Swallow: N.P.O. On diet & fluids |
| |N.P.O. + PEG/RIG | |
| | |Swallowing difficulties noted: Yes No |
| |Special Diet: Coeliac Diabetic Other………. |If yes, describe_______________________ |
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| |Medication given: Normally |Enteral feed: Yes No __________________ |
| |Crushed/Liquid form Non- orally |Subcutaneous fluids: Yes No ____________ |
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| |Any swallowing difficulties reported: |Appetite: Usual Increased Decreased |
| |Yes No |Feeding: Independent Assisted |
| |If yes, describe:__________________________ | |
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| |Feeding: Independent Assisted |Referred to Dietician : Yes No Date ______ |
| | |Referred to SLT: Yes No Date ______ |
| |Condition of mouth _______________________ | |
| |Dentures: Yes No | |
| |Top Bottom _______________ | |
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| |Appetite/ Intake changed: Yes No | |
| |Weight _____ kg Height _____ m BMI _____ | |
| |Score 1) >20 = 0 18.5 – 20 = 1 5 days: Score 3) = Yes = 2 No = 0 | |
| |Score 1 = 2 = 3 = ______ | |
|Mobility. |Transfers: Ind Ass ×1 Ass×2 W/Stick |Transfers:_____________________________ |
| |Frame Sit to stand hoist Full Hoist | |
| |Other__________________________________ |Mobility: ______________________________ |
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| | |Seating: _______________________________ |
| |Mobility: Ind Ass×1 Ass×2 Unable | |
| |Mobility Aid (specify)_______________________ |Referred to Physio: YES NO |
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| | |Referred to OT: YES NO |
| |Stairs Mobility: Able/Unable | |
| |Outdoor Mobility: Able/Unable | |
| |Distance _______________________________ | |
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| |History of falls: YES NO | |
| |Number of Falls in past year:________________ | |
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| |Did the patient have a fear of falling: | |
| |YES NO | |
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| |Did the patient experience difficulties with | |
| |walking or balance: YES NO | |
|Work/Leisu|Patient’s Occupation:_____________________ | |
|re. |Meal Preparation:________________________ | |
| |Domestic Tasks:________________________ | |
| |Leisure Activities:_______________________ | |
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| |______________________________________ | |
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| |Alcohol: YES NO | |
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| |1. Are you a smoker? YES NO | |
| |2. Inform patient of smoke free campus policy | |
| |3. Offer use of NRT: YES NO | |
| |4. Informed of smoking cessation service | |
|Expressing| | |
|Sexuality.|Sexual concerns: YES NO |Sexual concerns: YES NO |
| |______________________________________ |_______________________________________ |
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| |Menstruating: YES NO |Altered body Image: YES NO |
| |______________________________________ |_______________________________________ |
|Badder/Bow|BLADDER HEALTH |Continent: YES NO |
|el |Catheterised YES NO | |
| | |If NO assessment commenced: YES NO |
| |Do you to the toilet more than 8 times in the day to pass urine? | |
| |Yes No |Describe nature of problem and management |
| | |_______________________________________ |
| |Do you get up more than once during the night to pass urine? | |
| |Yes No |Catheterised: YES NO |
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| |Do you leak urine? Yes No |Reason________________________________ |
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| |Do you have any other bladder problems (ie. |Review Date____________________________ |
| |Difficulties passing urine and or pain)? | |
| |Yes No |U.T.T.: YES NO |
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| |Have you lost control or leaked bowel motions? |M.S.U./C.S.U.: YES NO |
| |Yes No | |
| | |Record Intake/Output: YES NO |
| |Do you have any other bowel difficulties | |
| |(ie constipation or diarrhoea)? Yes No |Aperients: YES NO |
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| |How often does your bowel open? Yes No | |
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| |PAD USAGE | |
| |Do you wear a pad? Yes No | |
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| |Do you have to change you underclothes or wear | |
| |protection because of bladder or bowel leakage or soiling? | |
| |Yes No | |
SPEECH & Language tHERAPY INITIAL Assessment
Galway uNIVERSITY HOSPITALs
|PATIENT: |DATE: |
Language: Nil language deficits reported
|Functional Communication | |
|Orientation |Time Person Place |
|Yes/ No Response | |
|Auditory Comprehension |Object Recognition: Function Recognition: |
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| |2. Following Commands: |
|Verbal Expression | Automatic Speech: |
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| |2. Object Naming: Function Naming: |
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| |3. Divergent Naming: Convergent Naming: |
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| |4. Connected Speech: |
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| |5. Repetition: |
|Reading | |
|Writing | |
|Impression | |
Motor Speech Exam
Nil speech deficits reported
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|Respiration_____________________________________________________________________ |
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|Phonation: MPT-_______________Vocal Quality-_______________Loudness-_______________ |
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|Articulation_____________________________________________________________________ |
|______________________________________________________________________________ |
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|Resonance: Hyponasal _______________Hypernasal ______________WNL _____________ |
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|Prosody________________________________________________________________________ |
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|-Rate: Appropriate Inappropriate Describe_______________________ |
|-Stress: Appropriate Inappropriate Describe_______________________ |
|Connected Speech Sample: Conversation Reading Sample |
|Intelligibility |
|Normal |
|Reduced Describe___________________________ |
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|Apraxia |
|-Oral Apraxia screen indicated: Yes No -Verbal Apraxia screen indicated: Yes No |
|Impression: |
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|Plan |
|SLT Signature: |Bleep: |
Oromotor Examination Patient:
Facial Ms: Mandibular:
Labial: Lingual:
Palatal:
Cough: Phonation:
Swallow Assessment
Pre-Ax intake: NPO Modified Diet:
Normal Diet & Fluids Modified Fluids:
Presentation:
Baseline O2 sats: Ausc Pre-swallow:
ORAL TRIALS
|Consistencies Trialled | | | | | |
|Anterior Spillage | | | | | |
|Reduced bolus control | | | | | |
|Slow oral transit | | | | | |
|Reduced chewing | | | | | |
|Oral residue | | | | | |
|Reduced Laryngeal elevation | | | | | |
|Multiple swallows | | | | | |
|Gurgly/Wet voice | | | | | |
|Immediate coughing | | | | | |
|Delayed coughing | | | | | |
|Throat clearing | | | | | |
|Eye-tearing | | | | | |
|Increased Respiratory rate | | | | | |
|Other | | | | | |
|Nil overt signs of aspiration/ difficulty | | | | | |
Post Ax O2 sats: Ausc Post-Swallow:
Overt signs suggestive of aspiration present: Yes No
Recommendations
NPO
PO Diet: For all PO intake patient must be
Alert & seated upright during & 30 mins post Have clean mouth before & after
PO Fluids: Any deterioration in chest status, pyrexia or cough, contact SALT/Medical Team and place
Strategies: NPO or
PLAN: _____________________________________________________________
SLT: __________________________________________ Date: ___________________________
Department of Physiotherapy UHG
Stroke Assessment
Functional Status:
Power: (Oxford Scale: _/5)
|Joint: |Right: |Left: |Joint: |Right: |Left: |
|GHJ: | | |Hip: | | |
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|Elbow: | | |Knee: | | |
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|Wrist & | | |Ankle & | | |
|Hand: | | |Foot: | | |
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Shoulder Subluxation: Yes No ___________________ Pain: ___________________
|ROM |Right: |Left: | |Right: |Left: |
|GHJ: | | |Hip: | | |
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|Elbow: | | |Knee: | | |
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|Wrist & | | |Foot & Ankle: | | |
|Hand | | | | | |
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Signed: _____________________________________________________ Date:_____________________
|Tone: |Right UL |Left UL |Right LL |Left LL |
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|Sensation: |Right UL |Left UL |Right LL |Left LL |
|Light Touch: | | | | |
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|Proprioception: | | | | |
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________________________________________________________________________________________
|Co-Ordination: |Right UL |Left UL | |Right LL |Left LL |
|Finger/Nose: | | |Heel/Shin: | | |
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Nine Hole Peg Test (seconds) Right_________________ Left ____________________
Grip Strength (kg) Right_________________ Left_____________________
Problem List and Treatment Plan:
|No. |Body structure & Function/Activity Limitation |Treatment Plan |
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Goals:
|No. |Patient Goals |No. |Therapist Goals |
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Signed__________________________________________________________ Date____________________
Galway University Hospitals
Occupational Therapy Initial Stroke Evaluation
CURRENT FUNCTIONAL STATUS:
SITTING BALANCE:
SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL:
4 able to sit safely and securely for 2 minutes
3 able to sit 2 minutes under supervision
2 able to able to sit 30 seconds
1 able to sit 10 seconds
0 unable to sit without support 10 seconds
STANDING BALANCE:
STANDING UNSUPPORTED:
4 able to stand safely for 2 minutes
3 able to stand 2 minutes with supervision
2 able to stand 30 seconds unsupported
1 needs several tries to stand 30 seconds unsupported
0 unable to stand 30 seconds unsupported
SEATING AND POSTURAL ALIGNMENT:
FUNCTIONAL AIDS:
FUNCTIONAL TRANSFERS:
_______________________________________________________________________________________
UPPER EXTREMITIES: Affected extremity: L/R. Pre-morbid dominance: L/R.
Key Oxford scale: 0= No return 1=Trace 2=Poor 3=Fair 4= Good 5= Normal
Shoulder Elbow Forearm Wrist Hand
| |R |L |
|Localisation of touch | | |
|Light touch | | |
|Sharp/ blunt discrimination | | |
|Proprioception | | |
COGNITION: ___________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
COMMUNICATION: ______________________________________________________________
VISION AND PERCEPTION (star cancellation, 2dcotnab, circle scan, reading):
______________________________________________________________________________
______________________________________________________________________________
Modified Barthel Index Score:
Chair/bed transfers: 0 3 8 12 15 _____________________
Ambulation: 0 3 8 12 15
Ambulation/ WC: 0 1 3 4 5 _____________________
Stair climbing: 0 2 5 8 10
Toilet Transfer: 0 2 5 8 10 _____________________
Bowel control: 0 2 5 8 10
Bladder control: 0 2 5 8 10 _____________________
Bathing: 0 1 3 4 5
Dressing: 0 2 5 8 10 _____________________
Personal hygiene: 0 1 3 4 5
Feeding: 0 2 5 8 10 _____________________
SCORE:
Modified Barthel Index Score(See attached assessment Sheet): _____________________
|Score |Interpretation |
|0-20 |Total Dependence |
|21-60 |Severe Dependence |
|61-90 |Moderate Dependence |
|91-99 |Slight Dependence |
|-100 |Independence |
|Problems |Goal /Plan |
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Occupational Therapist: __________________________________________ Date: __________________
Nutrition:
Weight _______ Kg
Height _______ M
BMI _______ Kg/m²
Biochemistry
|Na |K |PO4²ˉ |Alb |Protein |Mg²⁺ | | |
| | | | | | | | |
Requirements from Schofield
KCalories __________
Protein __________
Fluid __________
Plan:
_______________________________________________________________________________________
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|Week 1 Ward/s |
|Patient Name RH No: |
|DAY NIGHT |
| |Patient name bracelet applied Yes No N/A | | |
|(1) |Safe environment maintained at all times. | | |
|Safety |*Assess need for cot sides & apply if appropriate as per guidelines. | | |
| |Ensure call bell is within reach at all times. | | |
| |Seen by Medical Team | | |
|(2) |Relatives spoken to re condition. Information given to relatives: written Verbal | | |
|Communication |Mood & Psychological needs assessed and recorded in communication sheet. | | |
| |Type: PVC/PICC/CVC/Portocath/Hickman or other_____________________ | | |
| |Date Inserted: ___________ Date to be changed / Removed: ___________ | | |
|(3) |Assessed each shift | | |
|IV Intravascular Device |Any signs of Infection / Pain at site: Yes No | | |
| |Dressing Intact: Yes No | | |
| |Site of IV device: Yes No | | |
| |Fluid Administered on advice of Dr /S<) | | |
| |Fluid Chart: 1) Commenced, 2) Maintained, 3) Discontinued. Record volume | | |
|(4) | | | |
|FLIUDS |Oral: 1) Normal, 2) Thickened/grade…………………. | | |
| |Non Oral: 3) Nil by mouth, 4) NG, 5) IVI, 6) Subcutaneous | | |
| |TPR/BP observations recorded and range | | |
|(5) |O2 | | |
|Obs |Oxygen Stats recorded on observation sheet (If saturations less than 92% on room air report to medical | | |
| |team) | | |
|(6) | | | |
|BLOOD |Blood sugars recorded & monitored as per medical instructions. | | |
|(7) |Prescribed medication given. Meds whole , Crush , Liquid | | |
|MEDS |Pain assessed and analgesia administered as prescribed | | |
| |Transfers: Ind Ass ×1 Ass×2 W/Stick | | |
| |Frame Sit to stand hoist Full Hoist | | |
|(8) |Other__________________________________ | | |
|Transfers/ | | | |
|Mobility |Mobility: Ind Ass×1 Ass×2 Unable | | |
| |Mobility Aid (specify)_______________________ | | |
| |Seating Arrangements: | | |
|(9) |1) Standard arm Chair, 2) OT Chair, 3) Cosy Chair, | | |
|Seating |Reposition patient 2 hourly if unable to move themselves | | |
| |Patient assisted with personal hygiene requirements: | | |
|(10) |1) Independence, 2) Assisted wash, 3) bed bath, 4) Shower. | | |
|Skin/Hygiene |Assist with oral hygiene: 1) 2 hourly, 2) 4 hourly, 3) twice daily, 4) Independence. | | |
| |Skin integrity observed. | | |
| |Swallow Assessment: Completed by speech & language: Yes No | | |
| |Consistency: (Advised by the Dr/Speech & Language Therapist) | | |
| | | | |
|(11) |Oral: 1) Normal, 2) Easy chew, 3) Mince/Hoist, 4) Smooth puree, 5) Liquidised, | | |
|Swallow/ |6) Oral trail……………………… 7) Special diet…………………… | | |
|Diet |Non Oral: 8) Nil by mouth, 9) NG, 10) PEG/RIG, 11) TPN | | |
| | | | |
| |Food Chart: 1) Commenced, 2) Maintained, 3) Discontinued | | |
| | | | |
| |MUST screening tool completed: Yes No | | |
| |Bowel Movements: Recorded on stool chart/observation chart. | | |
|(12) |1) Continent, 2) Incontinent, 3) Bowels not opened | | |
|BOWEL/ | | | |
|BLADDER |Urinary Continence: | | |
| |1) Incontinent, 2) Continent, 3) Catheter, 4) Urinal, 5) Commode | | |
| |Weight & Height: | | |
|(13) |1) Confirmed, 2) Recorded | | |
|Weekly |Weight once weekly W/S once/week Barthel score | | |
|(14) |Referred to Discharge coordinator | | |
|Referrals |Referred to Stroke Rehabilitation Ward (MPUH) | | |
| |Liase with Medical team re Investigations/ test results | | |
|Signatures: DAY 1 DAY Nocte |
| |
|_______________________________________________________________________________________________________ |
|NURSING Please initials in appropriate column and shift(s) Please leave no blanks, Enter N/A if not applicable |
|Week 1 Ward/s Please Initials in appropriate column and place signature at the bottom of page |
|Patient Name: RH NO: |
|Day 2 |Day 3 |Day 4 |Day 5 |Day 6 |Day 7 | |
|DAY |
|AM |AM |AM |AM |AM |AM |
|PM |PM |PM |PM |PM |PM |
|NOCTE |NOCTE |NOCTE |NOCTE |NOCTE |NOCTE |
|Week 2 Ward/s |
|Patient Name RH No: |
|DAY NIGHT |
| |Patient name bracelet applied Yes No N/A | | |
|(1) |Safe environment maintained at all times. | | |
|Safety |*Assess need for cot sides & apply if appropriate as per guidelines. | | |
| |Ensure call bell is within reach at all times. | | |
| |Seen by Medical Team | | |
|(2) |Relatives spoken to re condition. Information given to relatives: written Verbal | | |
|Communication |Mood & Psychological needs assessed and recorded in communication sheet. | | |
| |Type: PVC/PICC/CVC/Portocath/Hickman or other_____________________ | | |
| |Date Inserted: ___________ Date to be changed / Removed: ___________ | | |
|(3) |Assessed each shift | | |
|IV Intravascular Device |Any signs of Infection / Pain at site: Yes No | | |
| |Dressing Intact: Yes No | | |
| |Site of IV device: Yes No | | |
| |Fluid Administered on advice of Dr /S<) | | |
| |Fluid Chart: 1) Commenced, 2) Maintained, 3) Discontinued. Record volume | | |
|(4) | | | |
|FLIUDS |Oral: 1) Normal, 2) Thickened/grade…………………. | | |
| |Non Oral: 3) Nil by mouth, 4) NG, 5) IVI, 6) Subcutaneous | | |
| |TPR/BP observations recorded and range | | |
|(5) |O2 | | |
|Obs |Oxygen Stats recorded on observation sheet (If saturations less than 92% on room air report to medical | | |
| |team) | | |
|(6) | | | |
|BLOOD |Blood sugars recorded & monitored as per medical instructions. | | |
|(7) |Prescribed medication given. Meds whole , Crush , Liquid | | |
|MEDS |Pain assessed and analgesia administered as prescribed | | |
| |Transfers: Ind Ass ×1 Ass×2 W/Stick | | |
| |Frame Sit to stand hoist Full Hoist | | |
|(8) |Other__________________________________ | | |
|Transfers/ | | | |
|Mobility |Mobility: Ind Ass×1 Ass×2 Unable | | |
| |Mobility Aid (specify)_______________________ | | |
| |Seating Arrangements: | | |
|(9) |1) Standard arm Chair, 2) OT Chair, 3) Cosy Chair, | | |
|Seating |Reposition patient 2 hourly if unable to move themselves | | |
| |Patient assisted with personal hygiene requirements: | | |
|(10) |1) Independence, 2) Assisted wash, 3) bed bath, 4) Shower. | | |
|Skin/Hygiene |Assist with oral hygiene: 1) 2 hourly, 2) 4 hourly, 3) twice daily, 4) Independence. | | |
| |Skin integrity observed. | | |
| |Swallow Assessment: Completed by speech & language: Yes No | | |
| |Consistency: (Advised by the Dr/Speech & Language Therapist) | | |
| | | | |
|(11) |Oral: 1) Normal, 2) Easy chew, 3) Mince/Hoist, 4) Smooth puree, 5) Liquidised, | | |
|Swallow/ |6) Oral trail……………………… 7) Special diet…………………… | | |
|Diet |Non Oral: 8) Nil by mouth, 9) NG, 10) PEG/RIG, 11) TPN | | |
| | | | |
| |Food Chart: 1) Commenced, 2) Maintained, 3) Discontinued | | |
| | | | |
| |MUST screening tool completed: Yes No | | |
| |Bowel Movements: Recorded on stool chart/observation chart. | | |
|(12) |1) Continent, 2) Incontinent, 3) Bowels not opened | | |
|BOWEL/ | | | |
|BLADDER |Urinary Continence: | | |
| |1) Incontinent, 2) Continent, 3) Catheter, 4) Urinal, 5) Commode | | |
| |Weight & Height: | | |
|(13) |1) Confirmed, 2) Recorded | | |
|Weekly |Weight once weekly W/S once/week Barthel score | | |
|(14) |Referred to Discharge coordinator | | |
|Referrals |Referred to Stroke Rehabilitation Ward (MPUH) | | |
| |Liase with Medical team re Investigations/ test results | | |
|Signatures: DAY 1 DAY Nocte |
| |
|_______________________________________________________________________________________________________ |
|NURSING Please initials in appropriate column and shift(s) Please leave no blanks, Enter N/A if not applicable |
|Week 2 Ward/s Please Initials in appropriate column and place signature at the bottom of page |
|Patient Name: RH NO: |
|Day 2 |Day 3 |Day 4 |Day 5 |Day 6 |Day 7 | |
|DAY |
|AM |AM |AM |AM |AM |AM |
|PM |PM |PM |PM |PM |PM |
|NOCTE |NOCTE |NOCTE |NOCTE |NOCTE |NOCTE |
|Week 3 Ward/s |
|Patient Name RH No: |
|DAY NIGHT |
| |Patient name bracelet applied Yes No N/A | | |
|(1) |Safe environment maintained at all times. | | |
|Safety |*Assess need for cot sides & apply if appropriate as per guidelines. | | |
| |Ensure call bell is within reach at all times. | | |
| |Seen by Medical Team | | |
|(2) |Relatives spoken to re condition. Information given to relatives: written Verbal | | |
|Communication |Mood & Psychological needs assessed and recorded in communication sheet. | | |
| |Type: PVC/PICC/CVC/Portocath/Hickman or other_____________________ | | |
| |Date Inserted: ___________ Date to be changed / Removed: ___________ | | |
|(3) |Assessed each shift | | |
|IV Intravascular Device |Any signs of Infection / Pain at site: Yes No | | |
| |Dressing Intact: Yes No | | |
| |Site of IV device: Yes No | | |
| |Fluid Administered on advice of Dr /S<) | | |
| |Fluid Chart: 1) Commenced, 2) Maintained, 3) Discontinued. Record volume | | |
|(4) | | | |
|FLIUDS |Oral: 1) Normal, 2) Thickened/grade…………………. | | |
| |Non Oral: 3) Nil by mouth, 4) NG, 5) IVI, 6) Subcutaneous | | |
| |TPR/BP observations recorded and range | | |
|(5) |O2 | | |
|Obs |Oxygen Stats recorded on observation sheet (If saturations less than 92% on room air report to medical | | |
| |team) | | |
|(6) | | | |
|BLOOD |Blood sugars recorded & monitored as per medical instructions. | | |
|(7) |Prescribed medication given. Meds whole , Crush , Liquid | | |
|MEDS |Pain assessed and analgesia administered as prescribed | | |
| |Transfers: Ind Ass ×1 Ass×2 W/Stick | | |
| |Frame Sit to stand hoist Full Hoist | | |
|(8) |Other__________________________________ | | |
|Transfers/ | | | |
|Mobility |Mobility: Ind Ass×1 Ass×2 Unable | | |
| |Mobility Aid (specify)_______________________ | | |
| |Seating Arrangements: | | |
|(9) |1) Standard arm Chair, 2) OT Chair, 3) Cosy Chair, | | |
|Seating |Reposition patient 2 hourly if unable to move themselves | | |
| |Patient assisted with personal hygiene requirements: | | |
|(10) |1) Independence, 2) Assisted wash, 3) bed bath, 4) Shower. | | |
|Skin/Hygiene |Assist with oral hygiene: 1) 2 hourly, 2) 4 hourly, 3) twice daily, 4) Independence. | | |
| |Skin integrity observed. | | |
| |Swallow Assessment: Completed by speech & language: Yes No | | |
| |Consistency: (Advised by the Dr/Speech & Language Therapist) | | |
| | | | |
|(11) |Oral: 1) Normal, 2) Easy chew, 3) Mince/Hoist, 4) Smooth puree, 5) Liquidised, | | |
|Swallow/ |6) Oral trail……………………… 7) Special diet…………………… | | |
|Diet |Non Oral: 8) Nil by mouth, 9) NG, 10) PEG/RIG, 11) TPN | | |
| | | | |
| |Food Chart: 1) Commenced, 2) Maintained, 3) Discontinued | | |
| | | | |
| |MUST screening tool completed: Yes No | | |
| |Bowel Movements: Recorded on stool chart/observation chart. | | |
|(12) |1) Continent, 2) Incontinent, 3) Bowels not opened | | |
|BOWEL/ | | | |
|BLADDER |Urinary Continence: | | |
| |1) Incontinent, 2) Continent, 3) Catheter, 4) Urinal, 5) Commode | | |
| |Weight & Height: | | |
|(13) |1) Confirmed, 2) Recorded | | |
|Weekly |Weight once weekly W/S once/week Barthel score | | |
|(14) |Referred to Discharge coordinator | | |
|Referrals |Referred to Stroke Rehabilitation Ward (MPUH) | | |
| |Liase with Medical team re Investigations/ test results | | |
|Signatures: DAY 1 DAY Nocte |
| |
|_______________________________________________________________________________________________________ |
|NURSING Please initials in appropriate column and shift(s) Please leave no blanks, Enter N/A if not applicable |
|Week 3 Ward/s Please Initials in appropriate column and place signature at the bottom of page |
|Patient Name: RH NO: |
|Day 2 |Day 3 |Day 4 |Day 5 |Day 6 |Day 7 | |
|DAY |
|AM |AM |AM |AM |AM |AM |
|PM |PM |PM |PM |PM |PM |
|NOCTE |NOCTE |NOCTE |NOCTE |NOCTE |NOCTE |
Variance / Communication
Multi-Professional/Team: Please indicate your specialty
|Date/Time | |Signature |
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Variance / Communication
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Name:
Hospital Number:
|This initial assessment must be completed on admission & reassessed if: Their condition changes; Post-operatively; Epidural/ Peripheral nerve |
|block; Transferred to another ward, department, and hospital. |
|Categories |
|Tissue Malnutrition (May select 1 or more options) |
❖ Document all pressure ulcers Grade 2 and above as a clinical incident
❖ Risk assessment tools are only used as a guide and should NOT replace clinical judgement
-----------------------
Patient’s Name:
Address:
Hospital Number:
Date of Birth:
Affix ID Label
[pic]
Name: ________________________________________
Address: ______________________________________
______________________________________________
Hospital No: ______________ D.O.B:_______________
Please attach ID label
Patient’s Name:
Address:
Hospital Number:
Date of Birth:
Name: ___________________________
Address: _________________________
________________________________
Hospital No. _______ D.O.B. _______
Please attach address label
Addressograph
Bed Mobility: Sitting Balance:
Sit To Stand: Standing Balance:
Gait:
Addressograph
NAME
HOSPITAL NUMBER:
DATE OF BIRTH:
NAME
HOSPITAL NUMBER:
DATE OF BIRTH:
NAME
HOSPITAL NUMBER:
DATE OF BIRTH:
NAME
HOSPITAL NUMBER:
[pic][?]
hðÚhj[?]Œ5?CJ$OJ[?]QJ[?]^J[?]aJ$hðÚ5?CJ$OJ[?]QJ[?]^J[?]aJ$h¥ï5?CJ$OJ[?]QJ[?]^J[?]aJ$h
tæ5?CJ$OJ[?]QJ[?]^J[?]aJ$h"5?CJ$OJ[?]QJ[?]^J[?]aJ$#hF hðÚ5?CJOJ[?]QJ[?]^J[?]aJhðÚ5DATE OF BIRTH:
WATERLOW PRESSURE ULCER PREVENTION/TREATMENT POLICY
(Ring scores in table, add total)
................
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