4975 orthopaedic clerking sheet v4 - hip fracture · clerking sheet name: date of birth: hospital...
TRANSCRIPT
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Presenting complaint:
History of presenting complaint:
Incident details:
Orthopaedic Trauma Clerking Sheet
Name:
Date of Birth:
Hospital No:
NHS No:
Consultant:
Patient detailsor sticker
Date: ____ / ____ / ________ Time:
PD4975 v4 PRC PILOT
Issue date: November 2010Review date: November 2012
Events leading to any fall: Clear story of trip, slip or accident Palpitations, chest pain or SOB
Aura, fit, tongue biting, incontinence Dizzy, light headed, pale, sweaty
Other associated medical symptoms Unexplained loss of consciousness
Details: Other
Mechanism of injury: RTA / fall > 2 meters / fall < 2 meters / sport / stabbing / other assaultDetails:
RTA: Driver / FSP / RSP / cyclist / motorcyclist / pedestrian / intrusion / ejection / entrapment / other death
Protective devices: none / seatbelt / airbag / helmet / other
PILOT
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Patient name: .............................................................................
Hospital number: ....................................................................
Past medical history:
MI/angina Heart failure Pacemaker Hypertension Diabetes
Asthma/COPD DVT/PE Anticoagulated Jaundice Stroke/TIA
Epilepsy Dementia Smoking Alcohol
Psychiatric illness Previous surgery Other
Details:
Drug history: Allergies:
Occupation:
System enquiry:
Social history:
Admitted from: Own home/sheltered housing
Resisdential care/Nursing home/ long term care hospital
Rehabilitation unit
Acute hospital
Already in hospital
Other
Unknown
Walking ability indoors pre-admission:
Regularly walked without aids
Regularly walked with one aid
Regularly walked with two aids or frame
Unknown
Walking ability outdoors pre-admission:
Regularly walked without aids
Regularly walked with one aid
Regularly walked with two aids or frame
Wheelchair or bedbound
Unknown
Accompanied to walk indoors pre-admission: Yes No
Accompanied to walk outdoors pre-admission: Yes No
NB: Holiday residence/respite care is classifiedas admitted from ownhome
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Patient name: .............................................................................
Hospital number: ....................................................................
Airway:
Airway and cervical spine: clear / blood / vomit / stridor
Breathing:
Respiratory rate:________/min
O2Sats (% O2/air)
Circulation: Abdomen:
Peripheral pulses:
BP: ........................
cap. refil ............................. seconds
Temperature:
Peripheral oedema:
Neurological:Glasgow Coma Scale
Eye Opening Spontaneous = 4To command = 3To pain = 2None = 1
Verbal Response Oriented = 5Confused = 4Random = 3Grunts = 2None = 1
Motor Response Obeys = 6Localises pain = 5Withdraws = 4Flexes to pain = 3Extends to pain = 2None = 1
Total /15
Pupils:
Right size
reaction
Left size
reaction
Cranial nerves:
AMT
Age ...............
D.O.B. ...............
Year ...............
Place ...............
Time (to hour) ...............
Monarch ...............
WW1 ...............
Recognise 2 people ...............
Count 20-1 backwards ...............
Recall address ...............
Total / 10
Hand dominances (circle): R L
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Patient name: .............................................................................
Hospital number: ....................................................................
Power: (use MRC grading; x / 5)
right left right leftShoulder C5 Hip flexion L2/L3abductionElbow C5/C6 Knee extension L3/L4flexionWrist C6/C7 Foot dorsiflexion L4/L5extensionElbow C7/C8 EHL L5extension
Grip C7/C8 Knee flexion L5/S1
Finger T1 Foot plantarflexion S1/S2abduction
Reflexes: (mark: - - = absent; - = reduced;+ = normal; ++ = brisk)
right left
Biceps C6
Triceps C7
Knee L3/4
Ankle S1/S2
Plantar response right left
PR examination: (describe)
Perianal sensation:
Anal tone:
Anal squeeze:
Summary of neurological assessment:(include level and grade in spinal cord injuries and any suspected peripheral nerve injuries)
Spinal neurological assessment
Tone: (circle as appropriate) R L
Upper limbs normal flaccid spasticity clonus normal flaccid spasticity clonus
Lower limbs normal flaccid spasticity clonus normal flaccid spasticity clonus
Sensation: (mark and label areas of reduced or absent sensation)
Patient name: .............................................................................
Hospital number: ....................................................................
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Date: ____ / ____ / ________ Time:
VARIABLE VALUE POINTSAge 66-85 years 11
≥ 86 years 14Sex Male 4
Female 0Admission Hb ≤ 10 3
> 10 0Admission AMT ≤ 6 out of 10 4
> 6 out of 10 0Living in a Yes 4institution No 0Number of 0 0comorbidities 1 2
2 53 84 115 20
Total points:
NHFS Mortality NHFS Mortality NHFS Mortality11 3% 24 17% 37 57%12 4% 25 19% 38 60%13 4% 26 22% 39 64%14 5% 27 24% 40 67%15 5% 28 27% 41 70%16 6% 29 30% 42 73%17 7% 30 33% 43 76%18 8% 31 36% 44 78%19 9% 32 39% 45 81%20 10% 33 43% 46 83%21 12% 34 46% 47 85%22 13% 35 50% 48 86%23 15% 36 53%
Predicted 30 day mortality =
Musculoskeletal/pressure areas/bruises/wounds:
ECG: Musculoskeletal x-rays:
CXR:
Nottingham Hip Fracture Score (NHFS)
Comorbidities: CV disease, Malignancy, Stroke, Paget’s, Respiratory disease,Smoking, Renal disease, Steroids, Diabetes, Warfarin, Rheumatoid disease,Clopidogrel, Parkinson’s disease, 4 or more medications.
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Patient name: .............................................................................
Hospital number: ....................................................................
Main injuries / problems and action plan:
Initial treatment regime prompt:
Analgesia, antiemetics and aperients
Thromboprophylaxis prescribed Yes No
2o fracture prevention IV fluids Skin marking
Antibiotic cover Consent Trauma conference
Inform relatives if indicated
Has the patient ever been informed that they are at risk of CJD for public health purposes? Yes No
Has the patient ever been informed that they are at risk of vCJD for public health purposes? Yes No
Date: ____ / ____ / ________ Time:
Signature: Print:
Grade: Bleep: Date: ____ / ____ / ________ Time:
Routine pre-op. investigations Additional tests- in ALL patients - to be performed if indicated
Hb
WCC
Platelets
INR (if warfarin)
Na+
K+
Urea
Creatinine
Ca2+/albumin
Group and save
Blood glucose
LFT
Clotting screen
Arterial blood gases
pH
pO2
pCO2
BE
MRSA screen
Blood cultures
Sputum cultures
MSU
Result Sent Results
Authors: S Madan, C TimmJointly agreed by orthopaedic surgeons, anaesthetists and orthogeriatricians
PD5714 Issue date: April 2010. Revised September 2010. Review date: April 2011 PRC021/10_Rev1 Authors: Rhona Maclean & Becs Walsh, based on Department of Health National Tool
RISK ASSESSMENT FOR VENOUS THROMBOEMBOLISM (VTE) FOR ORTHOPAEDIC PATIENTS Date of admission: …………………………………………..
Risk assessment by: …………………………………………
Signature: ………………………………………………………
Designation: ……………………………………………………
Date of assessment: .…………………………………………
All patients should be risk assessed on admission to hospital. Patients should be reassessed
within 24 hours of admission and whenever the clinical situation changes Thrombosis (VTE) Risk Patient related Tick Admission related Tick Active cancer or cancer treatment Significantly reduced mobility for 3 days or more Age greater than 60 Hip or knee replacement Dehydration Hip fracture Use of oestrogen-containing contraceptive therapy
Total anaesthetic plus surgical time greater than 90 minutes
One or more significant medical comorbidities (e.g. heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions)
Surgery involving pelvis or lower limb with a total anaesthetic plus surgical time greater than 60 minutes
Personal history or first-degree relative with a history of VTE
Acute surgical admission with inflammatory or intra-abdominal condition
Obesity (BMI greater than 30kg/m2) Critical care admission Use of hormone replacement therapy Surgery with significant reduction in mobility Known thrombophilias Varicose veins with phlebitis Pregnancy or less than 6 weeks post partum – complete “Risk assessment for VTE in pregnancy & up to 6 weeks postpartum”
Bleeding Risk Patient related Tick Admission related Tick Active bleeding Neurosurgery, spinal surgery or eye surgery Acquired bleeding Other procedure with high bleeding risk Concurrent use of anticoagulants known to increase the risk of bleeding (see guideline “Peri-Operative Management of Patients on Oral Anticoagulant Therapy” via Intranet)
Lumbar puncture/ epidural/ spinal anaesthesia expected within the next 12 hours
Uncontrolled systolic hypertension (230/120 mmHg or higher)
Lumbar puncture/ epidural/ spinal anaesthesia within the previous 4 hours
Acute stroke Thrombocytopaenia (platelets below 75 x109/L) Untreated inherited bleeding disorders (such as haemophilia and von Willebrand’s disease)
Action taken (see overleaf for advice) by prescriber: ……………….……….(sign)………………………..…(print) Tick No thrombosis risk factors present so no prophylaxis needed Thrombosis risk factors present but no prophylaxis prescribed: state reason why (e.g. already on anticoagulation therapy, bleeding risk outweighs thrombosis risk)……………………………………………….
mechanical prophylaxis prescribed and/or enoxaparin prescribed whilst inpatient
Thrombosis risk factors present:
and patient to be considered for extended thromboprophylaxis
Name: Date of birth: Hospital No: NHS No: Consultant:
PD5714 Issue date: April 2010. Revised September 2010. Review date: April 2011 PRC021/10_Rev1 Authors: Rhona Maclean & Becs Walsh, based on Department of Health National Tool
RISK ASSESSMENT FOR VENOUS THROMBOEMBOLISM (VTE) FOR ORTHOPAEDIC PATIENTS
Assessment Assess all patients for VTE and bleeding risk factors using the tick-box table overleaf
Mechanical Prophylaxis
Prescribe anti-embolism stockings (unless contraindicated*) Anti-embolism stockings should be prescribed on the drug prescription and administration record and continued until mobility no longer significantly reduced. Use Flowtron® boots *** intraoperatively for all patients with VTE risk factors having a general anaesthetic whose surgical procedure is over 30 minutes.
Enoxaparin If thrombosis risk factors are present prescribe enoxaparin UNLESS bleeding risk outweighs VTE risk, or enoxaparin is contraindicated** Prescribe enoxaparin 40mg once daily, at 18:00 or 6-8 hours post-operatively unless contraindicated**, (use 20mg once daily if patient weighs less than 50kg or Cr greater than 200µmol/L in males or 150µmol/L in females). Continue until patient is no longer at increased risk of VTE. Pre-operative doses are not normally recommended.
Mobilisation Encourage ALL patients to mobilise as soon as possible and avoid dehydration Information Ensure patient is given booklet “Preventing Blood Clots while you are in Hospital” Monitoring for Heparin-Induced Thrombocytopaenia
• Inpatients: check FBC every two to three days between days 4 and 14 of enoxaparin administration. • Outpatients receiving enoxaparin: check FBC after 5-7 days and 10-14 days of starting enoxaparin.
If platelet count falls by more than 50% or symptoms of thrombosis develop, call Haematology for advice. Elective Hip replacement
Prescribe enoxaparin & mechanical prophylaxis as above; switch to oral rivaroxaban**** 10mg OD for 30 days on discharge
Elective Knee replacement
Prescribe enoxaparin & mechanical prophylaxis as above; switch to oral rivaroxaban 10mg OD for 10 days on discharge
Hip fracture Prescribe enoxaparin & mechanical prophylaxis as above; continue for 35 days post-operatively
Spinal surgery Omit enoxaparin before and for 24-48 hours post-op (use mechanical prophylaxis only) until risk of VTE outweighs risk of bleeding
Pelvic Surgery Prescribe enoxaparin & mechanical prophylaxis as above. Consider warfarin for 3 months at Consultant’s discretion
Upper limb surgery do not routinely offer VTE prophylaxis of any kind unless considered at high risk for VTE Circular fixators/ closed corticotomy
Prescribe mechanical prophylaxis with Flowtron® boots. If patient is at increased risk of VTE prescribe enoxaparin at discharge at Consultant’s discretion
Other orthopaedic surgery
Use mechanical prophylaxis as above. If patient has additional risk factors for VTE prescribe enoxaparin as above. Continue until mobility no longer significantly reduced
Lower limb casts Patients with additional risk factors for VTE (incl. cancer, previous VTE, family history VTE in first degree relative, known thrombophilia, pregnancy) or other high-risk patients may be prescribed oral rivaroxaban 10mg OD at discharge at the Consultant’s discretion until the cast is removed or normal mobility is regained. Pregnant patients and those in whom rivaroxaban is contra-indicated **** should continue on enoxaparin.
For further guidance on thromboprophylaxis see “STH Guidelines for the prevention of Venous Thromboembolic Disease” or NICE Clinical Guideline 92 “Venous Thromboembolism: Reducing the risk” via www.nice.org.uk/guidance/CG92 * Contraindications to anti-embolism stockings: peripheral arterial disease (suspected or proven); peripheral artery bypass grafting; peripheral neuropathy or other sensory impairment; fragile skin, gangrene, dermatitis or recent skin graft; known allergy to material; cardiac failure, severe leg oedema or pulmonary oedema from congestive heart failure, unusual leg size or shape, major limb deformity preventing correct fit. risk or creatinine clearance 15-29mls/min, or 30-49 mls/min and/ or taking interacting drugs. See BNF or product literature for more information. ** Contraindications to enoxaparin: patients with acute bacterial endocarditis, active major bleeding and conditions with a high risk of uncontrolled haemorrhage, including recent haemorrhagic stroke; thrombocytopenia in patients with a positive in-vitro aggregation test in the presence of enoxaparin (Heparin Induced Thrombocytopaenia); active gastric or duodenal ulceration; hypersensitivity to either enoxaparin sodium, heparin or its derivatives including other Low Molecular Weight Heparins. Use with caution in patients with hyperkalaemia. *** Contraindications to Flowtron® boots: known allergy to material of manufacture. ****Contraindications to Rivaroxaban: clinically significant active bleeding, pregnancy or breastfeeding, hepatic disease associated with coagulopathy and clinically relevant bleeding risk, hypersensitivity to the active substance or to any of the excipients, creatinine clearance less than 15mls/min. Use with caution in patients with moderate hepatic impairment, increased bleeding risk, creatinine clearance 15-29mls/min or 30-49 mls/min and/ or taking interacting drugs. See BNF or product literature for more information.