ACUTE STROKE INTEGRATED CARE PATHWAY

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1 PATIENT NAME H&C NUMBER DATE OF BIRTH CONSULTANT ACUTE STROKE INTEGRATED CARE PATHWAY ALL OTHER DISCIPLINES REMEMBER TO: Complete each section clearly and in full Tick boxes where appropriate Countersign each section If No is ticked record variance The Pathway must be retained in the patient s notes and any additional documentation must be attached behind this document. This pathway is intended for guidance only. It is no way intended to be prescriptive. Clinical decisions remain at the discretion of the clinician. 1

2 DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DATE DAY PRINT NAME DESIGNATION DATE / SIGNATURE 2

3 If patient is receiving Thrombolysis treatment complete section A below, and pages 4-13 of care pathway. Tick as you deliver care, if NO is ticked document reason in variation record on page 11. Section A. Patient attached to cardiac monitor: Yes No Abnormal arrhythmias observed in 1 st 24 hours; Yes N/A If Yes reported to Dr and recorded in evaluation Yes N/A Time 1 st syringe of Actilyse infused Time 2 nd syringe of Actilyse infused N/A On completion of Actilyse, giving set flushed with 20mls normal saline over 30 seconds: Yes No GCS / MEWS observations recorded every 15mins from commencement of infusion for 3 hours: Yes No Then every 30 mins for 6 hours: Yes No Then hourly for 15 hours: Yes No Observe for the following potential complications while recording GCS and MEWS observations, during ACTILYSE administration. GCS score dropped by 2 or more (from baseline GCS) Blood pressure reading > 230/120 mm Hg 2 Blood pressure readings taken 5 minutes apart > 185/110 mm Hg (if BP reading is > 185/110, repeat 5 minutes later. If BP remains > 185/110 stop infusion) Signs / Symptoms of anaphylaxis (angioedema, hypotension, bronchospasm, uticaria, itch) Signs / Symptoms of intracerebral haemorrhage (headache, vomiting, seizures, hypertension) Signs / Symptoms of systemic haemorrhage (hypotension, tachycardia, clammy, sweating, haematuria, haemoptysis, abdominal distension etc) If any of the above occurs during administration stop infusion and inform Dr immediately. Repeat C.T imaging of brain ordered for 24 hours from completion of Actilyse infusion: Yes No Date/Signature/ Designation. 3

4 PATIENT DETAILS / NURSING STAFF TO COMPLETE Name:... Known as:.... Address. Tel No.:.. DOB: Age:. Religion:... Occupation:... Married Single Widowed Divorced Retired Employed Unemployed First language Interpreter required? Yes N/A Next of Kin/Contact Person Name: Relationship:. Address: Tel No: Day. Tel No: Night. Additional contact.. GP: Tel No: Date of Symptom onset:.... Time of onset : Date / Time of admission to ward:... Property book: Yes N/A In safe: Yes N/A Identity bracelet: Yes No Allergies: Yes N/A If yes please specify: Presenting reason for admission: Baseline Observations BP right arm lying BP left arm lying Pulse GCS Temp. Record Blood Glucose Oxygen Saturation Level If below 95% Doctor informed Yes No Urinalysis Result MSU/CSU obtained: Yes N/A Results of CT Scan of brain: Infection control status on admission.. Date/Sign/Designation:. 4

5 REFERRALS TO ALL OTHER DISCIPLINES Following receipt of referral patients must be assessed by clinical Professions within the timeframe specified by their professional guidelines Date of referral Sign. Date Referral Received Sign. Date of assessment Sign. Physiotherapy Speech & Language Therapist: Swallow ** Speech Language Dietician Social Worker OT Stroke Nurse Specialist **Swallow screening may also be performed by nursing staff trained in Regional Swallow Screen 5

6 Record of Investigations and Referrals Date Investigations/ referrals Sign/Desig Date Investigations/ Referrals Sign/Designation 6

7 On Admission /First 24 hours/ Nursing staff to complete Tick as you deliver care, if NO is ticked document reason in variation record on page 11. Usual condition Pre-Stroke Changes due to present condition Prescribed Nursing Interventions Level of Consciousness Level of Consciousness Drowsy Semi-conscious (responds to speech fully) (not fully rousable) Conscious Unconscious GCS / MEWS observations commenced: Yes No Frequency.. OR as per Thrombolysis guidelines: Yes If GCS < 8 Dr informed: Yes N/A Breathing BM recorded: Breathing Yes No Colour:... Breathless: Lying Yes N/A Sitting Yes N/A On exertion Yes N/A Smokes: Yes N/A per day Colour:.. Breathless: Lying Yes N/A Sitting Yes N/A On exertion Yes N/A Home 02: Yes N/A Mobility Dependent Transfers with 2 Transfers with 1 Walks with 2 Walks with 1 Independent Mobility Bed rest Transfers with 2 Transfers with 1 Walks with 2 Walks with 1 Independent Appliances / prosthesis / Equipment, Specify :. Circulation Circulatory problems: Yes N/A Please state Appliances / prosthesis / equipment Specify:.. Manual handling risk assessment form completed: Yes No Referred to physiotherapy: Yes No Circulation 7

8 Tick as you deliver care, if NO is ticked document reason in variation record on page 11. Usual condition Pre-Stroke Changes due to present condition Prescribed Nursing Interventions Cleansing and Dressing Cleansing and Dressing Independent Independent Assistance required, specify below: 1 Person 2 Persons Upper body washing Upper body dressing Lower body washing Lower body dressing Assistance required, please specify below: 1 Person 2 Persons Upper body washing Upper body dressing Lower body washing Lower body dressing Dentures: Top Bottom Dentures: Top Bottom Oral hygiene assessed Yes N/A State mouth care frequency:.. Skin Condition (on admission) Pressure ulcers: Yes N/A Other Skin Condition Specify.. Communicating Visually Impaired Yes N/A Aids used: Hearing impaired Yes N/A Aids used:. Speech difficulty Yes N/A Specify:.. Eye Care: Yes N/A (Refer to Royal Marsden procedure manual for eye care / mouthcare) Referred to O.T: Yes No Skin Condition Braden Tool completed: Yes No Pressure ulcer prevention pathway / wound assessment completed Yes N/A Pressure mattress: Yes N/A if yes state type of mattress:. Pressure cushion Yes N/A Repositioning guidelines Yes N/A Communicating Visually Impaired Yes N/A Aids used:... Hemianopia Yes N/A Left Right: Speech Affected Yes N/A Specify:. Date/Signature/ Designation. 8

9 Tick as you deliver care, if NO is ticked document reason in variation record on page 11. Eliminating Usual condition Pre-Stroke Continent Urine Yes Incontinent of urine Yes Continent faeces Yes Incontinent of faeces Yes If incontinent describe nature of problem and management:.. Needs assistance toileting Yes Specify assistance needed:. Catheter insitu Yes Date last renewed. Reason for insertion. Eating and Drinking Special diet Yes Specify: Can prepare meals Yes Assistance feeding Yes If yes specify: Mental Health Short term memory loss Yes History of Depressive illness Yes Aggression verbal/physical Yes Attends psychiatric clinic Yes Changes due to present condition Prescribed Nursing Interventions Eliminating Continent Urine Yes Incontinent of urine Yes Continent faeces Yes Incontinent of faeces Yes If incontinent, continence assessment / care plan commenced: Yes No Catheter inserted Yes N/A Reason for insertion.. (Refer to Royal Marsden Procedure Manuel for catheter care) If patient is receiving Thrombolysis avoid insertion of catheter for 1 st 24 hours from commencement of infusion Eating and drinking Referred to SALT: Yes No Swallow screen performed: Yes No Nil by mouth Yes No N/A All patients that receive Thrombolysis should fast for 24 hours from commencement of infusion Must completed: Yes No Special diet: Yes No N/A Specify:. Normal diet and fluids : Yes No Assistance feeding Yes No N/A If yes specify: I.V. fluids in progress Yes No I.V. cannula in situ: Yes No I.V. cannulation chart commenced: Yes No Fluid Balance Chart: Yes No All patients that receive Thrombolysis must avoid insertion of additional cannulas for 1 st 24 hours from commencement of infusion Mental Health Oriented Yes Aggression verbal/physical Yes Agitated Yes Date/Signature/ Designation. 9

10 Please complete if patient is in receipt of: M T W T F S S Comments Home care support worker (personal care) Home care (practical care) Meals on wheels Day Centre Record number of carers Name Centre Day Hospital General Day Hospital Psychiatric District Nurse Reason for visits Community Psychiatric Nurse Respite Frequency Other e.g. private home help Social Assessment House Steps inside steps outside Bungalow/Downstairs flat Bathroom upstairs downstairs Upstairs flat Toilet upstairs downstairs Sheltered housing Ramps Residential Home Stair lift (Permanent / temporary) Nursing home (permanent / temporary) Pets: Support from family carer:. Living: Alone Main carer name: With partner Dependents Address: With other family Telephone number Referred to social worker: Yes No N/A Date/Signature/ Designation. 10

11 Nursing Summary Sheet Previous Medical History Current Medication State variance Reason (if known) Date Signature/ Design Date/Signature/ Designation. 11

12 DAY ONE Resus Status: Infection control precautions: Yes N/A Date/Time Care progress/evaluation Signature /Designation 12

13 DAY ONE Resus Status: Infection control precautions: Yes N/A Date/Time Care progress/evaluation Signature /Designation 13

14 PATIENT MANUAL HANDLING RISK ASSESSMENT (Hospital) Physical Disability: Weight, BMI & Height: Patient independent for all activities No further assessment required Further assessment required post op: YES/NO YES/NO YES/NO Handling Constraints/Behaviour Previous Mobility: Name & Destination: (Please print) Signature: History of Falls: YES/NO Date: Bed/Trolley to Bed DATE DATE DATE Dependence Aid Hoist & Sling Dependence Aid Hoist & Sling Dependence Aid Hoist & Sling Up/down bed Turning in bed Lying to sitting Bed/Chair to Chair/commode Walking Showering/ Bath Other Print Name & Designation: Any other comments / instructions Dependence Handling Aid Hoist Sling size/type Independent 0 Supervision S Assistance of 1 1 Assistance of 2 2 Assistance of 3 3 More than 3 state no. Flat slide sheets FS Roller slide sheets RS Handling Belt HB Transfer board TB Stand Aid SA Other Zimmer Rollator Crutches Walking Stick Bed profile Z R C WS BP Mobile Hoist Overhead hoist Standing hoist Bariatric Hoist MH OH SH BH Small Medium Large Extra Large Standard Toileting Disposable Other S M L XL St T D 14

15 Bed/Trolley to Bed Up/down bed Turning in bed Lying to sitting Bed/Chair to Chair/commode Walking Showering/Bath Other Print Name & Designation: PATIENT MANUAL HANDLING RISK ASSESSMENT - Continuation Sheet DATE DATE DATE Dependence Aid Hoist & Sling Dependence Aid Hoist & Sling Dependence Aid Hoist & Sling Any other comments / instructions Dependence Handling Aid Hoist Sling size/type Independent 0 Supervision S Assistance of 1 1 Assistance of 2 2 Assistance of 3 3 More than 3 state no. Flat slide sheets FS Roller slide sheets RS Handling Belt HB Transfer board TB Stand Aid SA Other Zimmer Rollator Crutches Walking Stick Bed profile Z R C WS BP Mobile Hoist Overhead hoist Standing hoist Bariatric Hoist MH OH SH BH Small Medium Large Extra Large Standard Toileting Disposable Other S M L XL St T D 15

16 BRADEN SCALE For Predicting Pressure Ulcer Risk (Initial assessment to be completed within 2 hours of admission) AT RISK: 18 OR LESS > Commence Pressure Ulcer Prevention Pathway LOW RISK: RISK FACTOR SENSORY PERCEPTION Ability to response meaningfully to pressure related discomfort 1.COMPLETELY LIMITED Unresponsive (does not moan, flinch or grasp) to painul stimuli, due to diminished level of sedation. DATE OF ASSESS SCORE/DESCRIPTION VERY LIMITED Repsonds only to Painful stimuli. Cannot communicate discomfort except by moaning or restlessness. 3. SLIGHTLY LIMITED Reponds only to verbal commands, but cannot always communicate discomfort or need to be turned 4. NO IMPAIRMENT Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. OR OR OR MOISTURE Degree to which skin is exposed to moisture. ACTIVITY Degree of physical activity. MOBILITY Ability to change and control body position. NUTRITION Usual food intake pattern 1 NPO: Nothing by Mouth. 2 IV: Intravenously 3 TPN: Total Parenteral nutrition. FRICTION & SHEAR TOTAL SCORE Limited ability to feel pain over most of body surface. 1. CONSTANTLY MOIST Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. 1. BEDFAST Confined to bed. Has a sensory Impairment Has some sensory which limits the abilty to feel impairment pain which limits or ability to feel pain or discomfort over ½ of discomfort in 1 or 2 body. extremities. 2. VERY MOIST Skin is often, but not Always moist. Linen must be changed at least once a shift. 2. CHAIRFAST Ability to walk, severely limited or non-existent. cannot bear own weight and/or must be assisted into chair or wheelchair. 1. COMPLETELY IMMOBILE 2. VERY LIMITED Does not make even slight Makes occasional slight changes in body or extremity changes in body or position without assistance. OR extremity position but unable to make frequent or significant changes independently. 3. OCCASSIONALLY MOIST 4.RARELY MOIST Skin is occasionally Skin is usually dry, moist, requiring an linen only requires extra linen change changing at routine approximately once a intervals. day. 3. WALKS OCCASIONALLY 4. WALKS Walks occasionally during FREQUENTLY day, but for very short Walks outside the room distances, with or without at least twice a day and assistance. inside room at least Spends the majority of each once every 2 hours shift in bed or chair. during walking hours. 3. SLIGHTLY LIMITED 4. NO LIMITATIONS Makes frequent though Makes major and slight change in body or frequent changes in extremity position position without independently. assistance. 1. VERY POOR 2. PROBABLY 3. ADEQUATE 4. EXCELLENT Never eats a complete meal. INADEQUATE Eats over ½ of most Eats most of every rarely eats more that 1/3 of Rarely eats a complete meals. Eats a total of 4 meal. Never any food offered. meal and generally eats servings of protein (meat refuses a meal. eats two servings or less of only about ½ of any food dairy products) each day. Usually eats a total protein (meat or dairy products) offered. Protein intake Occasionally will refuse a of 4 or more per day. Takes fluids poorly. includes only 3 servings of supplement if offered. does not take a liquid dietary meat or dairy products a supplement day. Occasionally will take a dietary supplement. OR Is NPO 1 and/or maintained Receives less than optimum Is on a tube feeding or on clear fluids or IV 2 for more amount of liquid diet or tube TPN 3 regime which than five days. feeding. probably meets most of nutritional needs. 1. PROBLEM 2. POTENTIAL PROBLEM 3. NO APPARENT Requires moderate to maximum Moves feebly or requires PROBLEM assistance in moving. minimum assistance. Moves in bed and in complete lifting without sliding during a move skin chair independently and against sheets is impossible. Ppobably slides to some has sufficient muscle Frequently slides down in bed extent against sheets, chair strength to lift up or chair, requiring frequent restraints or other devices. completely during move. repositioning with maximum Maintains relatively good Maintains good position assistance. Spasticity position in chair or bed in bed or chair at all contractures or agitation leads most of the time but times. to almost constant friction. occasionally slides down. OR servings of meat or dairy products. Occasionally eats between meals. does not require supplementation. ASSESS DATE TIME SIGNATURE OF REGISTERED NURSE ASSESS DATE TIME SIGNATURE OF REGISTERED NURSE

17 MUST DOCUMENTATION COMPLETE ON ADMISSION: Height.m Actual or Recalled Weight kg Actual or Recalled PRE-MUST QUESTIONS: Does the patient have :- DATE 1. A history of recent weight loss Yes / No Yes / No Yes / No 2. Altered/decreased appetite for 7 days Yes / No Yes / No Yes / No or more 3. A risk of under nutrition due to current Yes /No Yes / No Yes / No illness e.g. difficulty eating/drinking 4 A need for assistance with feeding Yes / No Yes / No Yes / No SIGNATURE If answer is No to all of the above questions repeat screening weekly. If answer is yes to any of the above questions then complete Must below. Also repeat weekly. Date Weight (Kg) / MUAC (cm) Height (m) / Ulna length (cm) BMI Score Score Score STEP 1 BODY MASS INDEX-BMI Over to Less than STEP 2 UNPLANNED WEIGHT LOSS IN LAST 3-6 MONTHS Less than 5% Between 5-10% More than 10% STEP 3 ACUTE DISEASE If patient is acutely ill AND there has been OR is likely to be no nutritional intake for more than 5 days TOTAL MUST SCORE: Low Risk =0 Medium Risk =1 High Risk 2 Does the patient require assistance to maintain nutrition and hydration? Yes / No 17

18 Malnutrition Universal Screening Tool (MUST) Flowchart LOW RISK MUST score = 0 MEDIUM RISK MUST score = 1 HIGH RISK MUST score = > 2 Record MUST Details Recommend a WELL BALANCED DIET Record MUST Details Recommend High Protein / Energy Diet Monitor intake for 3 days (record on food chart ) Record MUST Recordings Refer to Dietitian Recommend High Protein /Energy Diet Monitor intake as per Dietitian (record on food chart) RESCREEN Weekly RESCREEN 1 week and refer to dietitian if risk status changes 18

19 DAY 2 Tick as you deliver care, if NO is ticked record why in variation record. Unless stated otherwise activities below to be completed by Nurse Conscious Yes Unconscious Yes GCS observations recorded Yes No Frequency:. (Refer to Royal Marsden) Mews continued: Yes No Frequency. BM recorded: Yes No N/A Hydration IV fluids in progress: : Yes No N/A Subcutaneous fluids in progress : Yes N/A Fluid Balance Chart Recorded: Yes No N/A I.V. cannula in situ Yes N/A If cannula in situ, I.V. cannulation chart reviewed Yes No Nutrition: Nil by mouth Normal diet Modified Consistency (MC) Specify Thickened Fluids (TF) PEG NG Food Chart : Yes No N/A Mobility: If MC or TF referred to Dietician: Yes No Manual handling risk assessment form reviewed : Yes N/A Bed Rest Up to sit Transfer with hoist Transfers with 1 Transfers with 2 Mobile with 1 Mobile with 2 Mobile with aid Mobile with supervision Independent Date/Signature/ Designation. 19

20 DAY 2 Tick as you deliver care, if NO is ticked record why in variation record. Cleansing and Dressing: Personal Hygiene Independent 1 Person 2 Persons Assistance required: Lower Half Upper Half Bed bath Shower Dressing Independent 1 Person 2 Persons Assistance required: Lower Half Upper Half Eye Care: Yes No N/A Mouth Care: Yes No N/A (Refer to Royal Marsden) Skin Condition Pressure Mattress Yes No N/A If yes specify type: Pressure Relieving Cushion Yes No N/A If yes specify type: Wound assessment chart reviewed Yes No N/A Elimination: Continent Urine: Yes Incontinent of urine: Yes Continent faeces: Yes Incontinent of faeces: Yes If incontinent, continence assessment continued / care plan reviewed Yes No SRC in situ Yes N/A If SRC in situ, catheter care performed Yes No (refer to Royal Marsden) Bowels opened Yes N/A Date/Signature/ Designation. 20

21 Pain Intervention: DAY 2 Tick as you deliver care, if NO is ticked record why in variation record. Has patient pain as per MEWS chart: Yes N/A If yes details recorded in evaluation. Yes No Barriers to communication: Sleep pattern documented in evaluation: Yes No (record duration of sleep, number of times awakened, why patient awakened etc) Patient s condition and pathway discussed with patient/family/carer: Yes No Details of conversation recorded in evaluation: Yes No Physio to complete: Positioning: Transfers:.. Mobility / Gait:.. S&L Therapist to complete: Swallow assessment : Yes No N/A Communication assessment: Yes No N/A O.T. to complete: Assessment and treatment commenced / continued: Yes No N/A State variance Reason (if known) Date Signature Date/Signature/ Designation. 21

22 Resus Status: Infection control precautions: Yes N/A DAY 2 Date/Time Care progress/evaluation Signature /Designation 22

23 Resus Status: Infection control precautions: Yes N/A DAY 2 Date/Time Care progress/evaluation Signature /Designation 23

24 DAY 3 Tick as you deliver care, if NO is ticked record why in variation record. Unless stated otherwise activities below to be completed by Nurse Conscious Yes Unconscious Yes GCS observations recorded Yes No N/A Frequency: (Refer to Royal Marsden) Mews continued: Yes No N/A Frequency. BM recorded: Yes No N/A Hydration IV Therapy in progress: : Yes N/A Subcutaneous fluids in progress: Yes N/A Fluid Balance Chart Recorded: Yes No N/A I.V. cannula in situ Yes N/A If cannula in situ, I.V. cannulation chart reviewed Yes No Nutrition: Nil by mouth Normal diet Modified Consistency (MC) Specify Thickened Fluids (TF) PEG NG Food Chart : Yes No N/A Mobility: If MC or TF referred to Dietician: Yes No Manual handling risk assessment form reviewed : Yes N/A Bed Rest Up to sit Transfer with hoist Transfers with 1 Transfers with 2 Mobile with 1 Mobile with 2 Mobile with aid Mobile with supervision Independent Date/Signature/ Designation. 24

25 DAY 3 Tick as you deliver care, if NO is ticked record why in variation record. Cleansing and Dressing: Personal Hygiene Independent 1 Person 2 People Assistance required: Lower Half Upper Half Bed bath Shower Dressing Independent 1 Person 2 Persons Assistance required: Lower Half Upper Half Eye Care Yes No N/A Mouth Care Yes No N/A (Refer to Royal Marsden) Skin Condition Pressure Mattress Yes No N/A If yes specify type: Pressure Relieving Cushion Yes No N/A If yes specify type: Wound assessment chart reviewed Yes No N/A Elimination: Continent Urine: Yes Incontinent of urine: Yes Continent faeces: Yes Incontinent of faeces: Yes If incontinent, continence assessment continued / care plan reviewed Yes No SRC in situ Yes N/A If SRC in situ, catheter care performed Yes No (refer to Royal Marsden) Bowels opened today: Yes Bowels opened in last 2 days: Yes Bowels not opened in 3 days Yes If Yes, Dr informed Yes No Date/Signature/ Designation. 25

26 Pain Intervention: DAY 3 Tick as you deliver care, if NO is ticked record why in variation record. Has patient pain as per MEWS chart: Yes N/A If yes details recorded in evaluation. Yes No Barriers to communication: Sleep pattern documented in evaluation: Yes No (record duration of sleep, number of times awakened, why patient awakened etc) Patient s condition and pathway discussed with patient/family/carer: Yes No Details of conversation recorded in evaluation: Yes No Physiotherapist to complete: Positioning: Transfers:.. Mobility /Gait:.. S&L Therapist to complete: Swallow assessment : Yes No N/A Communication assessment: Yes No N/A OT to complete: Assessment and treatment continued: Yes No N/A State variance Reason (if known) Date Signature Date / Signature / Designation 26

27 Resus Status: Infection control precautions: Yes N/A DAY 3 Date/Time Care progress/evaluation Signature /Designation 27

28 DAY 3 Resus Status: Infection control precautions: Yes N/A Date/Time Care progress/evaluation Signature /Designation 28

29 DAY 4 Tick as you deliver care, if NO is ticked record why in variation record. Unless stated otherwise activities below to be completed by Nurse Conscious Yes Unconscious Yes GCS observations recorded Yes N/A Frequency: (Refer to Royal Marsden) Mews continued: Yes No N/A Frequency. BM recorded: Yes No N/A Hydration IV Therapy in progress: Yes N/A Subcutaneous fluids in progress: Yes N/A Fluid Balance Chart Recorded: Yes N/A I.V. cannula in situ Yes N/A If cannula in situ, I.V. cannulation chart reviewed Yes No Nutrition: Nil by mouth Normal diet Modified Consistency (MC) Specify Thickened Fluids (TF) PEG NG Food Chart : Yes No N/A Mobility: If MC or TF referred to Dietician: Yes No Manual handling risk assessment form reviewed : Yes N/A Bed Rest Up to sit Transfer with hoist Transfers with 1 Transfers with 2 Mobile with 1 Mobile with 2 Mobile with aid Mobile with supervision Independent Date/Signature/ Designation. 29

30 DAY 4 Tick as you deliver care, if NO is ticked record why in variation record. Cleansing and Dressing: Personal Hygiene Independent 1 Person 2 People Assistance required: Lower Half Upper Half Bed bath Shower Dressing Independent 1 Person 2 Persons Assistance required: Lower Half Upper Half Eye Care Yes No N/A Mouth Care Yes No N/A (Refer to Royal Marsden) Skin Condition Pressure Mattress Yes No N/A If yes specify type: Pressure Relieving Cushion Yes No N/A If yes specify type: Wound assessment chart reviewed Yes No N/A Elimination: Continent Urine: Yes Incontinent of urine: Yes Continent faeces: Yes Incontinent of faeces: Yes If incontinent, continence assessment continued / care plan reviewed Yes No SRC in situ Yes N/A If SRC in situ, catheter care performed Yes No (refer to Royal Marsden) Bowels opened today: Yes Bowels opened in last 2 days: Yes Bowels not opened in 3 days Yes If Yes, Dr informed Yes No Date/Signature/ Designation. 30

31 Pain Intervention: DAY 4 Tick as you deliver care, if NO is ticked record why in variation record. Has patient pain as per MEWS chart: Yes N/A If yes details documented in evaluation. Yes No Barriers to communication: Sleep pattern documented in evaluation: Yes No (record duration of sleep, number of times awakened, why patient awakened etc) Patient s condition and pathway discussed with patient/family/carer: Yes No Details of conversation recorded in evaluation: Yes No Physio to complete: Positioning: Transfers:.. Mobility /Gait:.. S&L Therapist to complete: Swallow assessment : Yes No N/A Communication assessment: Yes No N/A OT to complete: Assessment and treatment continued: Yes No N/A State variance Reason (if known) Date Signature Date/Signature/ Designation. 31

32 Resus Status: Infection control precautions: Yes N/A DAY 4 Date/Time Care progress/evaluation Signature /Designation 32

33 DAY 4 Resus Status: Infection control precautions: Yes N/A Date/Time Care progress/evaluation Signature /Designation 33

34 DAY 5 Tick as you deliver care, if NO is ticked record why in variation record. Unless stated otherwise activities below to be completed by Nurse Conscious Yes Unconscious Yes GCS observations recorded Yes No N/A Frequency: (Refer to Royal Marsden) Mews continued: Yes No N/A Frequency. BM recorded: Yes No N/A Hydration IV Therapy in progress: Yes No N/A Subcutaneous fluids in progress: Yes N/A Fluid Balance Chart Recorded: Yes No N/A I.V. cannula in situ Yes N/A If cannula in situ, I.V. cannulation chart reviewed Yes No Nutrition: Nil by mouth Normal diet Modified Consistency (MC) Specify Thickened Fluids (TF) PEG NG Food Chart : Yes No N/A Mobility: If MC or TF referred to Dietician: Yes No Manual handling risk assessment form reviewed : Yes N/A Bed Rest Up to sit Transfer with hoist Transfers with 1 Transfers with 2 Mobile with 1 Mobile with 2 Mobile with aid Mobile with supervision Independent Date/Signature/ Designation. 34

35 DAY 5 Tick as you deliver care, if NO is ticked record why in variation record. Cleansing and Dressing: Personal Hygiene Independent 1 Person 2 People Assistance required: Lower Half Upper Half Bed bath Shower Dressing Independent 1 Person 2 Persons Assistance required: Lower Half Upper Half Eye Care Yes No N/A Mouth Care Yes No N/A (Refer to Royal Marsden) Skin Condition Pressure Mattress Yes No N/A If yes specify type: Pressure Relieving Cushion Yes No N/A If yes specify type: Wound assessment chart reviewed: Yes No N/A Elimination: Continent Urine: Yes Incontinent of urine: Yes Continent faeces: Yes Incontinent of faeces: Yes If incontinent, continence assessment continued / care plan reviewed Yes No SRC in situ Yes N/A If SRC in situ, catheter care performed Yes No (refer to Royal Marsden) Bowels opened today: Yes Bowels opened in last 2 days: Yes Bowels not opened in 3 days Yes If Yes, Dr informed Yes No Date/Signature/ Designation. 35

36 DAY 5 Tick as you deliver care, if NO is ticked record why in variation record. Pain Intervention: Has patient pain as per MEWS chart: Yes N/A If yes details documented in evaluation: Yes No Barriers to communication: Sleep pattern documented in evaluation: Yes No (record duration of sleep, number of times awakened, why patient awakened etc) Patient s condition and pathway discussed with patient/family/carer: Yes No Details of conversation recorded in evaluation: Yes No Physiothearapist to complete: Positioning:. Transfers: Mobility/ Gait:. S&L Therapist to complete: Swallow assessment : Yes No N/A Communication assessment: Yes No N/A OT to complete: Assessment and treatment continued: Yes No N/A State variance Reason (if known) Date Signature 36 Date/Signature/ Designation.

37 Resus Status: Infection control precautions: Yes N/A DAY 5 Date/Time Care progress/evaluation Signature /Designation 37

38 DAY 5 Resus Status: Infection control precautions: Yes N/A Date/Time Care progress/evaluation Signature /Designation 38

39 DAY 6 Tick as you deliver care, if NO is ticked record why in variation record. Unless stated otherwise activities below to be completed by Nurse Conscious Yes Unconscious Yes GCS observations recorded Yes No N/A Frequency: (Refer to Royal Marsden) Mews continued: Yes No N/A Frequency. BM recorded: Yes No N/A Hydration IV Therapy in progress: Yes N/A Subcutaneous fluids in progress: Yes No N/A Fluid Balance Chart Recorded: Yes N/A I.V. cannula in situ Yes N/A If cannula in situ, I.V. cannulation chart reviewed Yes No Nutrition: Nil by mouth Normal diet Modified Consistency (MC) Specify Thickened Fluids (TF) PEG NG Food Chart : Yes No N/A Mobility: If MC or TF referred to Dietician: Yes No Manual handling risk assessment form reviewed : Yes N/A Bed Rest Up to sit Transfer with hoist Transfers with 1 Transfers with 2 Mobile with 1 Mobile with 2 Mobile with aid Mobile with supervision Independent Date/Signature/ Designation. 39

40 DAY 6 Tick as you deliver care, if NO is ticked record why in variation record. Cleansing and Dressing: Personal Hygiene Independent 1 Person 2 Persons Assistance required: Lower Half Upper Half Bed bath Shower Dressing Independent 1 Person 2 Persons Assistance required: Lower Half Upper Half Eye Care Yes No N/A Mouth Care Yes No N/A (Refer to Royal Marsden) Skin Condition Pressure Mattress Yes No N/A If yes specify type: Pressure Relieving Cushion Yes No N/A If yes specify type: Wound assessment chart reviewed: Yes No N/A Elimination: Continent Urine: Yes Incontinent of urine: Yes Continent faeces: Yes Incontinent of faeces: Yes If incontinent, continence assessment continued /care plan reviewed Yes No SRC in situ: Yes N/A If SRC in situ, catheter care performed Yes No (refer to Royal Marsden) Bowels opened today: Yes Bowels opened in last 2 days: Yes Bowels not opened in 3 days Yes If Yes, Dr informed Yes No Date/Signature/ Designation. 40

41 DAY 6 Tick as you deliver care, if NO is ticked record why in variation record. Pain Intervention: Has patient pain as per MEWS chart: Yes N/A If yes document details in evaluation. Barriers to communication: Sleep pattern documented in evaluation: Yes No (record duration of sleep, number of times awakened, why patient awakened etc) Patient s condition and pathway discussed with patient/family/carer: Yes No Details of conversation recorded in evaluation: Yes No Physio to complete: Positioning:. Transfers: Mobility/Gait:.. S&L Therapist to complete: Swallow assessment : Yes No N/A Communication assessment: : Yes No N/A OT to complete: Assessment and treatment continued: Yes No N/A State variance Reason (if known) Date Signature Date/Signature/ Designation. 41

42 Resus Status: Infection control precautions: Yes N/A DAY 6 Date/Time Care progress/evaluation Signature /Designation 42

43 DAY 6 Resus Status: Infection control precautions: Yes N/A Date/Time Care progress/evaluation Signature /Designation 43

44 DAY 7 Tick as you deliver care, if NO is ticked record why in variation record. Unless stated otherwise activities below to be completed by Nurse Conscious Yes Unconscious Yes GCS observations recorded Yes No N/A Frequency: (Refer to Royal Marsden) Mews continued: Yes No N/A Frequency. BM recorded: Yes No N/A Hydration IV Therapy in progress: Yes No N/A Subcutaneous fluids in progress: Yes N/A Fluid Balance Chart Recorded: Yes No N/A I.V. cannula in situ Yes N/A If cannula in situ, I.V. cannulation chart reviewed Yes No Nutrition: Nil by mouth Normal diet Modified Consistency (MC) Specify Thickened Fluids (TF) PEG NG Food Chart : Yes No N/A Mobility: If MC or TF referred to Dietician: Yes No Manual handling risk assessment form reviewed : Yes N/A Bed Rest Up to sit Transfer with hoist Transfers with 1 Transfers with 2 Mobile with 1 Mobile with 2 Mobile with aid Mobile with supervision Independent Date/Signature/ Designation. 44

45 DAY 7 Tick as you deliver care, if NO is ticked record why in variation record. Cleansing and Dressing: Personal Hygiene Independent 1 Person 2 Persons Assistance required: Lower Half Upper Half Bed bath Shower Dressing Independent 1 Person 2 Persons Assistance required: Lower Half Upper Half Eye Care Yes No N/A Mouth Care Yes No N/A (Refer to Royal Marsden) Skin Condition Pressure Mattress Yes No N/A If yes specify type: Pressure Relieving Cushion: Yes No N/A If yes specify type: Wound assessment chart reviewed: Yes No N/A Elimination: Continent Urine: Yes Incontinent of urine: Yes Continent faeces: Yes Incontinent of faeces: Yes If incontinent, continence assessment continued / care plan commenced Yes No SRC in situ: Yes N/A If SRC in situ, catheter care performed Yes No (refer to Royal Marsden) Bowels opened Yes Bowels opened today: Yes Bowels opened in last 2 days: Yes Bowels not opened in 3 days Yes If Yes Dr informed Yes No Date/Signature/ Designation. 45

46 DAY 7 Tick as you deliver care, if NO is ticked record why in variation record. Pain Intervention: Has patient pain as per MEWS chart: Yes N/A If yes details documented evaluation. Yes No Barriers to communication: Sleep pattern documented in evaluation: Yes No (record duration of sleep, number of times awakened, why patient awakened etc) Patient s condition and pathway discussed with patient/family/carer: Yes No Details of conversation recorded in evaluation: Yes No Physio to complete: Positioning: Transfers:.. Mobility/Gait:. S&L Therapist to complete: Swallow assessment : Communication assessment:. OT to complete: Assessment and treatment continued: Yes No N/A State variance Reason (if known) Date Signature Date/Signature/ Designation. 46

47 Resus Status: Infection control precautions: Yes N/A DAY 7 Date/Time Care progress/evaluation Signature /Designation 47

48 DAY 7 Resus Status: Infection control precautions: Yes N/A Date/Time Care progress/evaluation Signature /Designation 48

49 Date DISCHARGE PLAN Estimated date of discharge (to be completed within 24 hours of admission) Discharge arrangements confirmed with patient / carer Yes N/A Record carers name: Mode of transport (e.g ambulance, relative) Time Ambulance booked: Booking number:. Target time:.. If ambulance is delayed Bed / Site Manager informed Yes GP letter given and explained to patient / carer Yes Medications given and explained to patient / carer Yes Patients own medication returned to patient / carer Yes N/A Patient has received written information re: discharge medications Yes Patient property returned Yes N/A (record to whom this was given) Out patient appointment given Yes N/A (record to whom appointment given) Discharge advice given including point of contact should complications arise following discharge Yes Tracker form completed Yes N/A Ward returns book completed Yes Cannula removed Yes N/A Referred to District Nurse Yes N/A (Record reason eg. Continence management, wound management, Equipment etc) Signature/ Designation Patient for discharge to Own Home Residential Home Nursing Home Relatives Home If discharge address is different to patients home address record new address: Discharge Nurse: Time of discharge: Discharge Code: Transfer of Patient to a Nursing Home or other Hospital Transferred to: Patient / Relative/ Carer informed Name: Staff informed of transfer Name: CREST transfer form completed By whom: 49

50 DISCHARGE PLAN Speech and Language Therapist to complete Communication/swallow advice to patient, carer Yes N/A Addition of thickener to discharge medication list Yes N/A SALT follow up required Yes N/A Referred to Specialist Community Stroke Team: Yes No N/A Date/ Sig Physiotherapist to complete EQUIPMENT Date Ordered Signature Date delivered/collected Signature Walking stick Zimmer frame / Rollator Other Mobility upon discharge: Independent Zimmer frame/rollator With supervision Uses wheelchair Walking stick Chair bound Has patient had a stair assessment Yes N/A Referred to Specialist Community Stroke Team: Yes No N/A Occupational Therapist to complete Are equipment needs met for discharge Yes N/A OT Home / Access Visit completed Yes N/A OT discharge summary enclosed Yes N/A Home exercise programme Yes N/A Referred to Specialist Community Stroke Team: Yes No N/A Date / Signature Social Worker to complete Services to be installed upon discharge: Date services to be commenced Date / Sign State variance Reason (if known) Date Signature 50

51 WEEKLY WARD MD TEAM MEETING Date Week Evaluation Goals Signature/ Designation 51

52 WEEKLY WARD MD TEAM MEETING Date Week Evaluation Goals Signature/ Designation 52

53 WEEKLY WARD MD TEAM MEETING Date Week Evaluation Goals Signature/ Designation 53

54 WEEKLY WARD MD TEAM MEETING Date Week Evaluation Goals Signature/ Designation 54

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