stroke clinical pathway checklist acute - medicalclinical pathway checklist patient id inclusion...

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m Discharge Criteria - original to stay on patient chartm MAR Sheet - original to stay on patient chart

m Anticoagulant Record - original to stay on patient chart

m Teaching Checklist - original to stay on patient chartm Caregiver Checklist - original to stay on patient chart

GREY BRUCE HEALTH NETWORK

HOW TO USE THE CLINICAL PATHWAY

STROKE

This is a proactive tool to avoid delays in treatment and discharge.

These are not orders, only a guide to usual order.

TRANSFER PATIENTS: If patient is transferred to another hospital in Grey-

Bruce or to CCAC, send a copy of the following:

HEALTH CARE PROFESSIONALS: Place appropriate symbol in space

provided: ie done not done or symbol provided and relevant.

Place N/A in any box where the task is not applicable to the patient.

Additional tasks due to patient individuality can be added to the pathway in

“OTHER” boxes and/or Progress Notes. NOT ALL TASKS WILL APPLY TO

EVERY PATIENT.

ACUTE - MEDICAL

CLINICAL PATHWAY CHECKLIST

PATIENT ID

INCLUSION CRITERIA:

All Stroke patients over 18 years of age admitted to hospital.

MULTIDISCIPLINARY TEAMS: Sign and date appropriate sheet on first

contact with patient and each day the patient is seen.

Place the Clinical Pathway in the nurses clinical area of the chart. All health

care professionals should fill in the master signature sheet at the front of the

Pathway. Addressograph/sticker each page of the Pathway.

Updated Dec 2014 © 2004-2014 Grey Bruce Health Network

1Review Dec 2016

NAME

(Please Print)INITIAL SIGNATURE

DESIGNATION

(RN / RPN/ OTHER)

All rights reserved. No part of this document may be reproduced or transmitted, in any form

or by any means, without the prior permission of the copyright owner.Updated Dec 2014 © 2004-2014 Grey Bruce Health Network

2Review Dec 2016

PAIN ASSESSMENT: SCORE 0 - 10

URINE COLOUR:CATHETER TYPE AND SIZE:

OTHER:

ASSESSMENT

(OBSERVATIONS/

MEASUREMENTS/

ELIMINATION)

TREAT TEMPS >37.5 *NOTIFY PHYSICIAN FOR TEMP > 38.5

ECG

LABORATORY /

DIAGNOSTICSCT SCAN

OTHER:

BLOOD WORK (Specifically CBC, APTT, INR, ELECTROLYTES,

CREATININE, GLUCOSE)

CONTINUOUS CARDIAC MONITOR /

RHYTHM STRIPS INTERPRETTED AND ATTACHED

* DOES PATIENT HAVE KNOWLEDGE / DOCUMENTED HISTORY OF

HAVING AN IRREGULAR HEART RATE / PREVIOUS STROKE?

* RELEVENT / EMERGENT COMORBIDITIES DOCUMENTED

ER PHASEON

TRANSFER

CHEST ASSESSMENT: C - Clear *A - Adverse sounds

ER ADMISSION SIGNATURE:

ER TRANSFER SIGNATURE:

PATIENT ID

PROCESS

**Immediate Notification of the Acute Stroke Multidisciplinary Team is recommended on admission**

THOSE PATIENTS STAYING LONGER THAN 3 HOURS IN ER WILL HAVE ACUTE PHASE ACTIVATED

ACUTE - MEDICAL

DATE / TIME

__________

DATE / TIME

__________


INITIAL ASSESSMENT NATIONAL INSTITUTES OF HEALTH STROKE

SCALE (NIHSS) FLOW SHEET, then Q2H x 24 hours

(Indicate Score)

STROKE

*NOTIFY PHYSICIAN IF SBP > 220 OR DBP > 120 FOR 2 OR MORE

READINGS 5-10 MIN APART

OTHER:

CLINICAL PATHWAY CHECHLIST

INITIAL VITAL SIGNS + O2 SATS

P = Done O = Not Done N/A = Not Applicable

* requires descriptive charting in progress notes

EMERGENCY PHASE

0 - 3 HOURS

MONITOR FLUID INTAKE AND OUTPUT:

V - Voided C - Catheter I - Incontinent

Updated Dec 2014

© 2004-2014 Grey Bruce Health Network 3Review Dec 2016

`

ADVANCE DIRECTIVE DISCUSSION ADDRESSED

CONSULTS



ACUTE - MEDICAL PATIENT ID

PROCESS

EMERGENCY PHASE

0 - 3 HOURS P = Done O = Not Done N/A = Not Applicable


OTHER:

MOBILITY/ACTIVITYBED REST

OTHER:

TREATMENTS/

INTERVENTIONS

IV SITE ESTABLISHED / INSITU AND SATISFACTORY

2ND IV SITE ESTABLISHED / INSITU AND SATISFACTORY

OTHER:

TRANSFER

STROKE

PSYCHOSOCIAL

SUPPORT/

EDUCATION

PATIENT / FAMILY INFORMED OF DIAGNOSIS / REASON FOR

ADMISSION

ADDRESS IMMEDIATE CONCERNS

NUTRITIONNPO

DATE / TIME

__________

DATE / TIME

__________

ER PHASEON

TRANSFER

CONFIRM ORDER FOR ACUTE STROKE MULTIDISCIPLINARY TEAM

ENTERED IN CERNER AS:

C - Confirmed stroke OR U - Unconfirmed stroke

REPORT CALLED TO RECEIVING UNIT INDICATED TIME: __________

INFECTION CONTROL SCREENING QUESTIONS REVIEWED FOR

APPROPRIATE BED PLACEMENT

OTHER:

MEDICATIONS

ISCHEMIC NON-THROMBOLYTIC / NON-HEMMORAGIC STROKE ONLY:

ASA 160 mg PO @ ___________________

BEST MEDICATION RECONCILIATION FORM COMPLETED AND SIGNED

ISCHEMIC STROKE THROMBOLYTIC THERAPY ONLY:

ALTEPLASE (tPA) @ _____________________

OTHER:

ACETAMINOPHEN FOR TEMPERATURE > 37.5

ER ADMISSION SIGNATURE:

ER TRANSFER SIGNATURE:

Updated Dec 2014


Date

Time

Description Score Score Score Score

1a. Level of consciousness

(LOC)

0 Alert - Alert

1 Drowsy - wakens with stimulation

2 Stuporou - (requires repeated stimuli)

3 Coma

1b. LOC, questions

(month, age)

0 Answers both correctly

1 Answers one correctly

2 Answers neither correctly

1c. LOC, commands

(open/close eyes, make fist, release)

0 Performs both correctly

1 Performs one correctly

2 Performs neither correctly

2. Best gaze

(patient follows examiner's finger)

0 Normal

1 Partial gaze palsy

2 Forced deviation

3. Visual

(introduce visual stimulus)

0 No visual loss

1 Partial hemianopia

2 Complete hemianopia

3 Bilateral hemianopia

4. Facial palsy

(show teeth, raise eyebrowns, squeeze

eyes shut)

0 Normal

1 Minor asymmetry

2 Partial paralysis (lower face)

3 Complete

5a. Motor arm - Left

(elevate arm to 90° and score

drift/movement)5b. Motor arm - Right

(as above)

6a. Motor leg - Left

(elevate leg to 30° and score

drift/movement)6b. Motor leg - Right

(as above)

7. Limb ataxia

(finger-nose, heel down shin)

0 Absent

1 Present in one limb

2 Present in two or more limbs

X Amputation, joint fusion

8. Sensory

(pin prick to face, arm, trunk, and leg -

compare side to side)

0 Normal

1 Partial loss

2 Dense loss

9. Best language

(name item, describe a picture and

read sentences)

0 No aphasia

1 Mild to moderate aphasia

2 Severe aphasia

3 Mute, global aphasia

10. Dysarthria

(evaluate speech clarity by patient

read or repeat listed words)

0 Normal articulation

1 Mild to moderate slurring

2 Severe (near uninteligible or worse)

X Intubated or other physicial barrier

11. Extinction and Inattention

(use information from prior testing)

0 No neglect

1 Partial neglect

2 Profound neglect

National Institutes of Health

Stroke Scale Flow Sheet

0 No drift

1 Drift

2 Some effort against gravity

3 No effort against gravity

4 No movement

X Amputation, joint fusion 0 No drift

1 Drift

2 Some effort against gravity

3 No effort against gravity

4 No voluntary movement

X Amputation, joint fusion etc

TOTAL SCORE

Initials of Examiner

Category

NIHSS - Q2H x 24 hours, then twice per shift x 48 hours, then QSHIFT x 4 days 5 of 25

NIHSS Administration and Scoring Tips

1A: LOC – Overall Alertness: Interact with patient by asking a couple of general questions (ie. “How are you today?”)Scoring:0 = Alert

1 = Drowsy – arousable with minor stimulation

2 = Stuporous – repeated stimulation to attend and/or painful stimuli to make movements

3 = Comatous or makes only reflex, posturing movements with painful stimuli

If the patient is comatous, DISCONTINUE the NIH and complete the Glasgow Coma Scale

1B: LOC – Questions: Ask patient two very specific questions:

1. Month

2. Age

If present, family can translate if language barrier is present

Patient may write answer if expressively aphasic

Scoring:

0 = Answers both correctly

1 = Answers one correctly [*or if patient has a language barrier, score 1*]

2 = Answers neither correctly [*receptive aphasic patients also score 2*]

1C: LOC – Commands: Ask patient to follow two specific commands:

1. “Close your eyes, and now open.”

2. “Make a fist with (unaffected) hand, now open.” [*may substitute different commands, if needed*]

Pantomime the commands and may repeat the command one additional time, if needed

Give credit if a real attempt is made but not completed due to weakness etc.

Scoring:

0 = Performs both correctly

1 = Performs one task correctly

2 = Performs neither task correctly [*if patient has a comprehension deficit, score 2*]

2: Best Gaze: Tests volunteer horizontal eye movement – move finger from side to side asking patient to track

that movement by moving eyes only, keep asking patient to “follow the target”

If patient does not accurately follow your finger, then use the “dolls eye maneuver” (Hold upper

eyelids open and quickly but gently turn head side to side, watching for any eye movements. If eyes

remain fixed in mid-position, then patient has total gaze paresis. )

If patient is receptively aphasic and does not understand, then make eye contact and move your

head from side to side and see if patient follows

Scoring:

0 = Normal [*eye movement crossing midline in both directions*]

1 = Partial gaze palsy [*some eye movement, but not normal as above*]

2 = Forced deviation or total gaze paresis [*if eyes cannot be moved*]

October 2014 of 25

3: Visual Fields: Testing all 4 quadrants (both upper & both lower) of both eyes by using ‘finger movement’, ‘finger

counting’, or if needed, ‘visual threat’

Make sure patient is looking directly into your eyes during testing

Cover one eye and test all 4 quadrants, then switch eye covered and test other eye in all 4

quadrants

Have patient point when they see the finger move or tell you how many fingers they see if using

finger counting

Make sure you line yourself up with the patient and check that you are testing within their visual

field by closing your eye as well

If patient is unable to follow directions or has impaired vision preventing above testing, then

‘visual threat’ can be used in all 4 quadrants

If patient has known severe visual loss or blindness in 1 eye, then just test and score the other eye

accordingly

Scoring:

0 = No visual field loss [*also those that respond to visual threat in all 4 quadrants score 0*]

1 = Partial hemianopsia [*misses vision in 1 quadrant of both eyes*]

2 = Complete hemianopsia [*misses half (2 quadrants) of both eyes*]

3 = Bilateral hemianopsia [*misses all (4 quadrants) of both eyes, cortical blindness*]

4: Facial Palsy: Assessing full (upper, middle, and lower) facial movement

Ask and use pantomime to have patient perform the 3 following tasks:

1. “Show me your teeth.”

2. “Squeeze eyes shut, as hard as you can.”

3. “Raise your eyebrows.”

For poorly responsive patients or patients unable to follow directions, use noxious stimuli and score the

symmetry of their grimace

Scoring:

0 = Normal symmetrical movement

1 = Minor asymmetry [*mild asymmetry while smiling, this is the proper score if function is less

than clearly normal*]

2 = Partial paralysis [*when there is a clear-cut facial droop/asymmetry of lower face*]

3 = Complete paralysis [*when there is clear-cut asymmetry and decreased facial movements in all 3

facial areas*]

5: Arm Motor & 6: Leg Motor: Start with unaffected limb side first (with arms, ensure palms are down)

Help patient by placing limb in desired start position

Begin counting out loud and count with fingers as well

Start counting immediately upon release of the limb; 10 count for arms, and 5 count for legs

Scoring:

0 = No drift [*limb remains steady after initial dip*]

1 = Drift [*some drift or bouncing of limb, but limb does not touch support/bed*]

2 = Some effort against gravity [*patient is able to hold limb for at least a count of one, but limb drifts

down to touch the support before end of total count*]

3 = No effort against gravity [*limb drops immediately to support, but when asked/encouraged,

movement is produced – any movement at all counts*]

October 2014 of 25

4 = No voluntary movement [*limb drops immediately to support and patient cannot illicit any movement at all

when asked/encouraged*]

7: Limb Ataxia: Testing for in-coordinated (‘jerky’, ‘scissoring’, ‘difficulty initiating’, ‘difficulty stopping’, ‘past-

pointing’ type of movements) not general weakness; ataxia is only scored as present if ataxia is

demonstrated

Patients who are too weak to perform test or too weak to properly complete test (ie. arm drops, leg

falls off shin) are scored as normal, this is weakness not ataxia

If the test is not performed because patient has comprehension deficits and cannot understand,

then ataxia is not seen, so it is scored as normal

Have patient perform two tests, starting with unaffected side, repeating each movement 2 – 3

times if needed, to accurately assess

1. Finger-nose-finger – “Take your finger and touch my finger, now touch your nose.”

2. Heel-shin test – “Place your heel on your shin and now run your heel down your shin and then back

up again.”

Scoring:

0 = Normal [*normal coordination that is well performed and smooth or too weak to perform or

receptive aphasia and does not perform – all score 0*]

1 = Present in one limb

2 = Present in two or more limbs

8: Sensory: Testing sensation using a series of pinpricks, testing face & proximal portion of all 4 limbs (do not use

hands or feet due to neuropathies)

Patient’s eyes should be open

‘Pinprick’ one side and then the other, asking patient if they feel it on each side; If felt on both sides, ask if

there is any difference between the two sides

In aphasic or stuporous patients, use noxious stimuli and observe for level of grimace

Scoring:

0 = Absent [*no loss of sensation, pinpricks or noxious stimuli are felt equally throughout*]

1 = Partial loss [*pinpricks or noxious stimuli are felt on both sides but in at least one area a difference between

the level of sharpness is felt/demonstrated*]

2 = Dense loss [* in at least one area , pinpricks or noxious stimuli are NOT felt at all *]

9: Best Language: Here you are assessing the patient’s ability to communicate, to share ideas. You are assessing their

fluency of thought and comprehension, NOT the clarity of their speech

This requires 3 parts:

1. Cookie jar picture

2. Item card

3. Phrases card

Ask patient to describe the scene in the ‘cookie jar’ picture – you are looking for an expression of

basic understanding of the picture and their ability to convey same

Ask patient to name each item on the item card, score as correct things that are similar in

appearance (ie. hand is acceptable for glove; feather is acceptable for leaf, etc.)

Ask patient to read the phrases on the phrase card – if unable to read, have patient repeat

October 2014 of 25

If patient has a visual field deficit and only sees half of the card, base your score on the half they

described

Score is based on your overall sense of patient’s language ability, not clarity

Scoring:

0 = No aphasia [*expression of ideas are fluent and clear, like you or I*]

1 = Mild to moderate aphasia [*evidenced by loss of fluency of thought or comprehension, but this

reduction still allows you to understand essentially what is being expressed*]

2 = Severe aphasia [*responds or attempts to respond but is unable to be understood, has

demonstrated ability to follow 1-step command previously*]

3 = Mute, global aphasia [*no attempt to respond and unable to follow 1-step commands*]

10. Dysarthria: This tests patient’s articulation and clarity of speech

Important to not tell patient the purpose of test

Ask patient to read the words on the ‘word card’, if patient cannot read, have the patient repeat

the words after you

Scoring:

0 = Normal speech [*reads all words with clarity and no slurring or articulation problems

(ie. stammering or stuttering*]

1 = Mild to moderate dysarthria [*slurring or impaired clarity but can be understood*]

2 = Severe dysarthria [*cannot be understood in any meaningful way or is mute*]

11. Extinction and Inattention (Neglect): Tests for neglect or inattention by using TWO stimuli:

1. Tactile/touch

2. Visual

Ask patient to close eyes and provide tactile stimuli by alternately touching (R) and (L) asking

patient to identify side(s), by stating or pointing to left, right , or both

If patient extinguishes one side (does not recognize when being touched on both sides

simultaneously), then this part of the test is positive for neglect

Next introduce visual stimuli by having patient look directly at you while you assess his/her ability

to respond to ‘wiggling’ fingers in upper and lower (R ) quadrants and upper and lower (L) quadrants

Have patient identify if the finger is moving on the right, left, or both

If patient extinguishes one side (does not recognize the finger wiggling on that side when both

fingers are wiggling simultaneously), then this part of the test is positive for neglect

Scoring:

0 = No neglect [*does not demonstrate neglect with either tactile or visual stimuli or if patient is

blind/severe vision loss and visual stimuli cannot accurately be tested and

patient does not demonstrate tactile neglect*]

1 = Partial neglect [*patient demonstrates neglect with either tactile stimuli or with visual stimuli*]

2 = Profound neglect [*patient demonstrates neglect with BOTH tactile and visual stimuli*]

October 2014 of 25

INITIALS:

CATHETER

REMOVED:

INITIALS:

URINE COLOUR:

RESTRAINT OBSERVATION Q _______ MIN

1

MODIFIED RANKIN SCALE (Indicate Score)

PERFORMANCE

INDICATORS

PATIENT SAFETY

CUES

OTHER:

TREAT TEMPS >37.5 * NOTIFY PHYSICIAN FOR TEMP > 38.5

CHEST ASSESSMENT Q4H: C - Clear * A - Adverse sounds

PAIN ASSESSMENT Q4H: * I - Intervention

SCORE 0 - 10

INTAKE AND OUTPUT QSHIFT (Nofity physician for < ________ mL/h)

V - Voided C - Catheter I - Incontinent HNV - Has Not Voided

NATIONAL INSTITUTES OF HEALTH STROKE SCALE (NIHSS):

Q2H x 24 hours, then twice per shift x 48 hours, then QSHIFT x 4 days

OTHER:

BOWEL ROUTINE: C - Continent I - Involuntary O - Ostomy

BRADEN (SKIN) RISK ASSESSMENT COMPLETED

ON ADMISSION AND PRN (Indicate Score)

(Record QSHIFT on Checklist)

ACUTE CARE PHASE

PROCESSDATE: DATE:

DAY 1 DAY 2






STROKE

Pass / Fail keep NPO

DAY 3

DATE:

q Met q Not Met q N/ADYSPHAGIA SCREENING TOOL

COMPLETED (Once Q24H)

ASSESSMENT

(OBSERVATIONS/

MEASUREMENTS/

ELIMINATION)

VITAL SIGNS + O2 SATS:

(Thrombolytic increased frequency as ordered)

(Non-Thrombolytic - Day 1: Q4H Day 2: QID Day 3: QSHIFT

* NOTIFY PHYSICIAN IF SBP > 220 OR DBP > 120 FOR 2 OR MORE

READINGS 5-10 MIN APART X 48 HOURS

RECORD REGULARITY OF HEART RATE (Note if patient aware of any

past anomalies) REG - Regular / IRREG - Irregular

PATIENT SAFETY CUE CARDS IN PLACE IN ROOM

(no straws, acute stroke checklist, fall risk symbol, etc)

MORSE FALL RISK ASSESSMENT COMPLETED

ON ADMISSION AND PRN (Indicate Score)

* MORSE FALL RISK INTERVENTIONS DOCUMENTED

* CONSENT OBTAINED FOR MINIMAL RESTRAINT FOR SAFETY AND

REASSESSED Q24H

Updated Dec 2014


NON-THROMBOLYTIC - ACTIVITY AS TOLERATED

THROMBOLYTIC - RESTRICTED AS ORDERED X 24 HOURS

* USE POSITIONING TO MAINTAIN PROPER BODY ALIGNMENT (SEE

"TIPS AND TOOLS" BOOK FOR REFERENCE PURPOSES)

HEAD OF BED ELEVATED MINIMUM 30 DEGREES FOR NPO / TUBE

FED PATIENTS

OTHER:

ACUTE CARE PHASE

DIET TEXTURE AS PER DYSPHAGIA SCREENING TOOL:

____________________________ (Diet order from physician only)

OTHER:

F - Feed self A - Assist C - Complete feed

(% of diet taken if not NPO)

SLEEP: R - Restless F - Fair W - Well

PERSONAL HYGIENE:

C - Complete / Cueing required A - Assist S - Self

INITIALS:

MOBILITY /

ACTIVITY

OTHER:

NUTRITION

OTHER:

ALTERNATE ROUTES DETERMINED FOR MEDS IF PATIENT NPO

PROCESS

SPECIAL EQUIPMENT:

STROKE



LABORATORY /

DIAGNOSTICS

BLOOD WORK AS ORDERED: (Documenting procedure completed)

SWABS MRSA & VRE COMPLETED ON ADMISSION THEN Q WEEKLY

DIAGNOSTICS:

ACUTE - MEDICAL

MEDICATIONS

TREATMENTS/

INTERVENTIONSIF NON-AMBULATORY: S - anti-emboli Stockings

or C - sequential Compression device

DATE:

DAY 1 DAY 2 DAY 3

PATIENT ID

(Record Q4H on Checklist) DATE: DATE:

* ASSESS RISK / NEED FOR DVT PROPHYLAXIS WITH PHYSICIAN

(Limited Mobiltiy / type of stroke significant in rationale for ordering)

IV AND/OR INTERMITTENT SET OBSERVATION AND SITE CARE Q1H

S - Satisfactory C - Changed R - Removed



NG FEEDING ESTABLISHED / CLINICAL NUTRITION CONSULT

PROTOCOL INITIATED / ENTER FEEDING ORDER SET INITIATED

Updated Dec 2014


DISCHARGE

PLANNING

Progress Notes:


STROKE

INITIALS:

* BARRIERS TO LEARNING DOCUMENTED (Patient or Family)

*SPECIFIC COMMUNICATIN / NEGLECT DEFICITS DOCUMENTED

ACUTE CARE PHASE

(Record Q4H on Checklist)



* ADDRESS PATIENT AND FAMILY ANXIETY IF APPLICABLE /

* ENCOURAGE PATIENT AND FAMILY TO ASK QUESTIONS

PSYCHOSOCIAL

SUPPORT/

EDUCATION GIVE PATIENT PATHWAY TO PATIENT / FAMILY

BEGIN / CONINUE TEACHING CHECKLIST WHEN APPROPRIATE

(Patient/family have received "LET'S TALK ABOUT STROKE" book)

ASSESS DISCHARGE CRITERIA DAILY

- Assess readiness for rehabilitation using referral form

- Complete Blaylock Discharge Planning Risk Assessment Screen

- Fax referral to Community Stroke Team when discharged

PROCESSDATE: DATE: DATE:

DAY 1 DAY 2 DAY 3



Updated Dec 2014


Progress Notes:


STROKE

PATIENT ID

* CLINICAL NUTRITION

* PHARMACIST

* OTHER:

* CCAC / DISCHARGE PLANNING

* SOCIAL WORKER


ACUTE - MEDICAL

* SPEECH/LANGUAGE PATHOLOGIST IF REQUIRED

CONSULTS(To be completed by

individual discipline

and signed with signature)

ACUTE CARE PHASE

MULTIDISCIPLINARY TEAM

P = Individual Disciplines have reviewed and

updates recorded accordingly

UPDATE PATIENT STROKE STATUS IN CERNER AS CONFIRMED OR

UNCONFIRMED TO ACTIVATE THE ACUTE STROKE

MULTIDICIPLINARY TEAM

* PHYSIOTHERAPY

* OCCUPATIONAL THERAPY

PDATE &

TIMESIGNATURE

Updated Dec 2014


q Patient q Family member

q Patient’s physician q Registered Nurse

q Other: Specify

DESCRIPTION QUESTIONS TO CONSIDER FOR GRADING

Baseline Discharge

q 0 q 0 No symptoms at all. No limitations.

q 1 q 1

No significant disability

despite symptoms; able to

carry out all usual duties and

activities.

Does person have difficulty reading or writing,

speaking, problems with balance/coordination,

visual problems, numbness, loss of movement,

difficulty swallowing or other symptoms resulting

from stroke?

q 2 q 2

Slight disability; unable to

carry out all previous

activities but able to look

after own affairs without

assistance.

Has there been a change in person’s ability to work

or look after others if these were roles before

stroke? Change in person’s ability to participate in

previous social and leisure activities? Problems

with relationships or become isolated?

q 3 q 3

Moderate disability; requiring

some help, but able to walk

without assistance.

Is assistance essential for preparing a simple meal,

doing household chores, looking after money,

shopping or traveling locally?

q 4 q 4

Moderately severe disability;

unable to walk without

assistance, and unable to

attend to own bodily needs

without assistance.

Is assistance essential for eating, using the toilet,

daily hygiene, or walking?

q 5 q 5

Severe disability; bedridden,

incontinent, and requiring

constant nursing care and

attention.

Requires constant care.

RN / MD Signature: /Baseline assessment Discharge assessment

MODIFIED RANKIN SCALE

q Discharge from Acute Care date: _____________________________

* This is to be completed on all Stroke as baseline (pre-treatment) and discharge from Acute Care*


Please indicate who provided the information:

GRADE

q Admission date: __________________________________________

Updated Dec 2014 © 2004-2014 Grey Bruce Health Network14

Review Dec 2016

DATE_______

DATE_______

DATE_______

RISK FACTOR 1 2 3 4

Sensory Perception: Ability

to respond meaningfully to

pressure—related discomfort

Completely

LimitedVery Limited

Slightly

Limited

No

Impairment

Moisture: Degree to which

skin is exposed to moisture

Constantly

MoistOften Moist

Occasionally

Moist

Rarely

Moist

Activity: Degree of Physical

ActivityBedfast Chair Fast

Walks

Occasionally

Walks

Frequently

Mobility: Ability to change

and control body position

Completely

ImmobileVery Limited

Slightly

Limited

No

Limitations

Nutrition: Usual food intake

patternVery Poor

Probably

InadequateAdequate Excellent

Friction and Sheer ProblemPotential

Problem

No Apparent

Problem

LOW RISK

(SCORE > 15)

Ongoing assessment for

change in status related to

any of the six risk areas

Includes “Moderate Risk Intervention” plus

requested referral to:

NURSE’S INITIALS

Nursing Intervention: Once you have assessed the patient and identified a risk category (high, moderate or low), carry

out the following interventions for the patient's risk category.

MODERATE RISK

(SCORE 13-14)

HIGH RISK

(SCORE < 12)

Document reassessment

weekly on Kardex

-Physiotherapy

-Continence management

SCORE

TOTAL SCORE

PATIENT ID

-Patient education re: prevention

-Monitor nutritional status

-Skin care tools used: prevention

mattresses or treatment (i.e. air

mattresses), creams, bed hoop,

trapeze, dressings

-Monitoring of pressure point areas -Dietitian

Initiate and document plan of care on

Kardex and Unit specific Progress

Notes including:


CLINICAL PATHWAY

ACUTE - MEDICAL

Braden Risk Assessment

STROKE

SCORING (Key on Reverse)

-Occupational Therapy

-Activity level (i.e. turning, positioning)

Updated Dec 2014


Braden Risk Assessment - page 2

RISK FACTOR

Moisture

Degree to which skin is

exposed to moisture

1. Constantly Moist

Skin is kept moist almost

constantly by perspiration,

urine, etc. Dampness is

detected every time patient is

moved or turned.

2. Often Moist

Skin is often, but not

always moist. Linen must be

changed at least once a shift.

3. Occasionally Moist

Skin is occasionally moist,

requiring an extra linen

change approximately once a

day.

4. Rarely Moist

Skin is usually dry, linen only

requires changing at routine

intervals.

Activity

Degree of physical

activity

1. Bedfast

Confined to a bed.

2. Chair Fast

Ability to walk severely

limited or nonexistent.

Cannot bear own weight

and/or must be assisted into

chair or wheelchair.

3. Walks Occasionally

Walks occasionally

during day, but for very short

distances, with or without

assistance. Spends majority

of each shift in bed or chair.

4. Walks Frequently

Walks outside the room at

least twice a day and

inside room at least once

every two hours during

waking hours.

Mobility

Ability to change and

control body position

1. Completely Immobile

Does not make even slight

changes in body or

extremity position without

assistance.

2. Very Limited

Makes occasional slight

changes in body or

extremity position, but

unable to make frequent or

significant changes

independently.

3. Slightly Limited

Makes frequent, though

slight changes in body or

extremity position

independently.

4. No Limitations

Makes major and frequent

changes in position

without assistance.

Nutrition 1. Very Poor

Never eats a complete meal.

Rarely eats more than 1/3 of

any food offered. Eats 2

servings or less of protein

(meat or dairy products) per

day. Takes fluids poorly.

Does not take a liquid dietary

supplement.

OR

Is on NPO and/or maintained

on clear fluids or IV for more

than 5 days.

2. Probably Inadequate

Rarely eats a complete meal

and generally eats only about

1/2 of any food offered.

Protein intake includes only 3

servings of meat or dairy

products per day.

Occasionally will take a

dietary supplement.

OR

Receives less than optimum

amount of liquid diet or tube

feeding.

3. Adequate

Eats over half of most meals.

Eats a total of 4 servings of

protein (meat, dairy products)

each day. Occasionally, will

refuse a meal, but will usually

take a supplement if offered.

OR

Is on a tube feeding or TPN

(Total Parenteral Nutrition)

regimen, which probably

meets most of nutritional

needs.

4. Excellent

Eats most of every meal.

Never refuses a meal.

Usually eats a total of 4 or

more servings of meat and

dairy products.

Occasionally eats

between meals. Does not

require supplementation.

Friction and Shear 1. Problem

Requires moderate to

maximum assistance in

moving. Complete lifting

without sliding against sheets

is impossible.

Frequently slides down in bed

or chair, requiring

frequent repositioning with

maximum assistance.

Spasticity, contractures or

agitation leads to almost

constant friction.

2. Potential Problem

Moves feebly or requires

minimum assistance.

During a move, skin probably

slides to some extent against

sheets, chair, restraints or

other devices. Maintains

relatively good position in

chair or bed most of the time,

but occasionally slides down.

3. No Apparent Problem

Moves in bed and in chair

independently and has

sufficient muscle strength to

lift up completely during

move. Maintains good

position in bed or chair at all

times.

SCORE/DESCRIPTION

Sensory Perception

Ability to respond

meaningfully

to pressure related

discomfort

1. Completely Limited

Unresponsive (does not

moan, flinch, or grasp) to

painful stimuli, due to

diminished level or

consciousness or sedation.

OR

Limited ability to feel pain

over most of body surface.

2. Very Limited

Responds only to painful

stimuli. Cannot

communicate discomfort

except by moaning or

restlessness.

OR

Has a sensory impairment,

which limits the ability to feel

pain or discomfort over 1/2 of

body.

3. Slightly Limited

Responds to verbal

commands but cannot always

communicate

discomfort or need to be

turned.

OR

Has some sensory

Impairment, which limits

ability to feel pain or

discomfort in 1 or 2

extremities.

4. No Impairment

Responds to verbal

commands. Has no

sensory deficit, which would

limit ability to feel or voice

pain or discomfort.

Updated Dec 2014

© 2004-2014 Grey Bruce Health Network 16Review Dec2016

INITIAL DATE

2

3

OTHER:

INITIALS:

MORSE FALL RISK ASSESSMENT *I - Interventions required

*CONSENT OBTAINED FOR MINIMAL RESTRAINT FOR SAFETY

AND REASSESSED Q24H

OTHER:

RESTRAINT OBSERVATION Q ______ MINUTES

BLOOD WORK

DIAGNOSTICS

OTHER:

ASSESSMENT

(OBSERVATIONS/

MEASUREMENTS/

ELIMINATION)

MODIFIED RANKIN SCALE IF PATIENT BEING DISCHARGED

FROM ACUTE CARE (Indicate Score)

LABORATORY /

DIAGNOSTICS

CHEST ASSESSMENT QSHIFT & PRN

C - Clear *A - Adverse sounds


BRADEN (SKIN) RISK ASSESSMENT UPDATED

PATIENT SAFETY

CUES

(UPDATED - PRN)

PATIENT SAFETY CUE CARDS IN PLACE IN ROOM

(no straws, acute stroke checklist, fall risk symbol)

VITAL SIGNS QSHIFT & PRN INCLUDING 02 SATS

TREAT TEMPS >37.5 *NOTIFY PHYSICIAN FOR TEMP >38.5

SKIN INTEGRITY QSHIFT *N - Needs intervention

NATIONAL INSTITUTES OF HEALTH STROKE SCALE (NIHSS)

QSHIFT FOR 4 DAYS

REASSESS DYSPHAGIA SCREENING TOOL IF INDICATED

P - Pass F - Fail

MONITOR BOWEL AND BLADDER ROUTINE

C - Continent I - Incontinent

PAIN ASSESSMENT QID & PRN *N - Needs intervention

Score 0 - 10

q Met q Not Met q N/A

PROCESS

TRANSITIONAL PHASE DAY: DAY:

DATE: DATE: DATE:



ACUTE - MEDICAL

STROKE

INTERDISCIPLINARY CONSULTS

COMPLETED

PATIENT ID

DAY:


* required descriptive charting in progress notes

PERFORMANCE

INDICATORS


TRIAGE (TRANSITION PLAN)

COMPLETED

Updated Dec 2014


INITIALS:

IF TUBE FEEDING T - Tolerated *A - Adjustments as ordered

MEDICATIONS

TREATMENTS/

INTERVENTIONS

OTHER:

MOBILITY/ACTIVITY

CONTINUE METHOD OF PATIENT TRANSFER AND DOCUMENT

IN PATIENT CARE PLAN (SEE "HEALTHY MOVES" BOOKLET

FOR REFERENCE PURPOSES)

USE POSITIONING TO MAINTAIN PROPER BODY ALIGNMENT

(SEE "TIP AND TOOLS" BINDER FOR REFERENCE PURPOSES)

DOCUMENT TOLERATED SITTING TIME DAILY

PSYCHOSOCIAL

SUPPORT/

EDUCATION

REVIEW PATIENT-SPECIFIC RISK FACTORS FOR

SECONDARY PREVENTION

ADDRESS QUESTIONS REGARDING PATIENT PATHWAY

AND/OR "LET'S TALK ABOUT STROKE" BOOKLET

ENGAGE FAMILY IN CAREGIVING

(Identify barriers and document for follow-up)

ADDRESS ANY QUESTIONS, FEARS AND ANXIETIES THE

PATIENT/FAMILY MAY HAVE

DATE: DATE:


PROCESS

DAY: DAY:

DATE:

STROKE


DAY:

q DIET TEXTURE AS PER DYSPHAGIA SCREENING TOOL

q REGULAR TEXTURE - HEALTHY HEART DIET

q SPECIAL DIET: ________________________

NUTRITION

OTHER:

IF NON-ABULATORY S - anti emboli Stockings

or C - sequential Compression device

BOWEL/BLADDER RETRAINING - PLAN DOCUMENTED AND

ONGOING *A - Adjustments made


TRANSITIONAL PHASE




ALL MEDICATIONS AND ROUTES ESTABLISHED

OTHER:

REASSESS IV WHEN ORAL INTAKE >1500 ML IN 24 HOURS

REMOVE/CHANGE IV SITE Q72H (INCLUDING TUBING)

% OF DIET TAKEN IF NOT NPO

REMIND PHYSICIAN OF REMOVAL OF URINARY CATHETER

REMOVAL DATE / TIME:

(Recommended after fluid balance established)

Updated Dec 2014


INITIALS:

Progress Notes:

CAREGIVER TRAINING/EDUCATION CHECKLIST COMPLETED

AND UNDERSTOOD BY CAREGIVER

REFERRAL TO CCAC DISCHARGE PLANNING INITIATED

DATE / TIME:

DISCHARGE

PLANNING

ASSESS DISCHARGE CRITERIA DAILY AND NOTIFY

COMMUNITY STROKE TEAM WHEN PATIENT DISCHARGED



REHABILITATION CONSULT DISCUSSION INITIATED

*BARRIERS TO REHABILITATION READINESS

- Plan commenced to optimize readiness / alternate plan

UPDATE AND REVIEW PLAN FOR DISCHARGE WITH

PATIENT/CAREGIVER


PROCESS

DAY: DAY: DAY:

DATE:


DATE: DATE:

STROKE



TRANSITIONAL PHASE

Updated Dec 2014


Progress Notes:

PATIENT ID

CONSULTS

(To be completed by

individual discipline

and signed with

signature)

TRANSITIONAL PHASE

MULTIDISCIPLINARY TEAM

P = Individual Disciplines have reviewed and

updates recorded accordingly

*PHYSIOTHERAPY

*OCCUPATIONAL THERAPY

*SPEECH/LANGUAGE PATHOLOGIST IF REQUIRED

*CLINICAL NUTRITION

*CCAC / DISCHARGE PLANNING

- assistive device needs identified and arranged

- home program developed and discussed

STROKE


ACUTE - MEDICAL


*PHARMACIST

*SOCIAL WORKER

*OTHER:

PDATE &

TIMESIGNATURE

Updated Dec 2014


VITAL SIGNS ACCORDING TO UNIT PROTOCOL

CHEST ASSESSMENT Q SHIFT ONLY IF DYSPHAGIC

PAIN ASSESSMENT PRN

SKIN INTEGRITY Q SHIFT

BRADEN RISK ASSESSMENT UPDATED

MONITOR BOWEL AND BLADDER ROUTINE

MODIFIED RANKIN SCALE IF PATIENT BEING DISCHARGED FROM ACUTE CARE

REASSESS DYSPHAGIA SCREENING TOOL IF INDICATED

OTHER:

TREATMENTS/

INTERVENTIONS

AMBULATION INDICATED ON KARDEX

DOCUMENT TOLERATED SITTING TIME DAILY

MULTIDICIPLINARY TEAM: RECOMMENDATIONS CLEARLY COMMUNICATED ON CARE PLAN

INITIALS:


STROKE

CLINICAL PATHWAY CHECKLISTPATIENT ID

ACUTE - MEDICAL

PROCESS

MAINTENANCE PHASE

BEYOND DAY 6 COMPLETED


"O" requires descriptive charting in progress notes

UPDATE PATIENT SAFETY CUES PRN

UPDATE THE PATIENT CARE PLAN ACCORDING TO THE FOLLOWING

LISTED CRITERIA, THEN DISCONTINUE THE STROKE PATHWAY.

CHARTING TO BE RESUMED ACCORDING TO UNIT CRITERIA.

FOR LONGER TERM PATIENTS CONSIDER OBTAINING ALC ORDERS

ASSESSMENT

(OBSERVATIONS/

MEASUREMENTS/

ELIMINATION)

IF NON-AMBULATORY, ANTI AMBOLI STOCKINGS/SEQUENTIAL COMPRESSION DEVICES

NUTRITION

q DIET TEXTURE AS PER DYSPHAGIA SCREENING TOOL

q REGULAR TEXTURE - HEALTHY HEART DIET

q SPECIAL DIET: ________________________

ACTIVITY AS TOLERATED REVIEWED DAILY

PATIENT SAFETY

CUES MRSA AND VRE SWABS Q WEEKLY (Next date to be completed indicated on Care Plan)

PUSH ORAL FLUIDS IF NOT NPO

DOCUMENTATION FOR TUBE FEEDING AND FEEDING TYPE

MOBILITY/ACTIVITY

TRANSFERS INDICATED ON CARE PLAN (SEE "HEALTHY MOVES" BOOKLET FOR

REFERENCE PURPOSES)

Updated Dec 2014


PSYCHOSOCIAL

SUPPORT/

EDUCATION

UPON PATIENT DISCHARGE, REFER TO PATHWAY DISCHARGE CRITERIA SHEET

INITIALS:

Progress Notes:


STROKE

CLINICAL PATHWAY CHECKLISTPATIENT ID

ACUTE - MEDICAL

STROKE TEACHING ON GOING

DISCHARGE

PLANNING

PROCESS

MAINTENANCE PHASE

BEYOND DAY 6 COMPLETED


"O" requires descriptive charting in progress notes

ASSESS DISCHARGE CRITERIA DAILY

ONGOING STRATEGY TO OVERCOME BARRIERS TO DISCHARGE IN PLACE

Updated Dec 2014


PROCESS INITIAL

4 DRIVING STATUS REVIEWED

5SECONDARY PREVENTION RISK

FACTORS ADDRESSED

LABORATORY /

DIAGNOSTICS

TREATMENTS/

INTERVENTIONS

NUTRITION

MOBILITY/ACTIVITY

CONSULTS

PERFORMANCE

INDICATORS

DATE MET



SPEECH/LANGUAGE AND/OR SWALLOWING FOLLOW UP

ARRANGED IF NEEDED

TRANSFER INFORMATION CHECKLIST COMPLETED



ACUTE - MEDICAL

REQUISITION FOR OUTPATIENT BLOOD WORK GIVEN

ASSESSMENT

(OBSERVATIONS/

MEASUREMENTS/

ELIMINATION)

STROKE

PATIENT ID

DISCHARGE CRITERIA

PATIENT AWARE OF RISK FACTORS AND MANAGEMENT

PATIENT AND FAMILY AWARE OF MANAGEMENT PLAN

CAREGIVER TRAINING/EDUCATION COMPLETED

CCAC DISCHARGE PLAN COMPLETED

- ASSISTIVE DEVICES ARRANGED AND IN HOME

FOLLOW UP OUTPATIENT THERAPY AS APPROPRIATE

ALL CONSULTS COMPLETED

- NOTIFY COMMUNITY STROKE TEAM OF DISCHARGE THROUGH

REFERRAL PROCESS

DISCHARE MEDICATIONS LIST EXPLAINED TO PATIENT AND FAMILY

BOWEL AND BLADDER ROUTINE ESTABLISHED

MEDICATIONS

REFERRAL TO STROKE PREVENTION CLINIC COMPLETED

PATIENT AND FAMILY HAVE UNDERSTANDING OF STROKE

EDUCATION

PSYCHOSOCIAL

SUPPORT/

EDUCATION

DISCHARGE TRANSPORTATION ARRANGED

SKIN INTEGRITY PLAN

NEED FOR COMMUNITY DIETITIAN REFERRAL IDENTIFIED

DISCHARGE

PLANNING

PERSCRIPTION GIVEN

PATIENT / FAMILY INDICATE THEY UNDERSTAND MEDICATIONS

PATIENT AND FAMILY AWARE OF FOLLOW UP APPOINTMENT

Updated Dec 2014


Progress Notes:

PATIENT ID


STROKE


ACUTE - MEDICAL

Updated Dec 2014


TRIAL – SEPT 2, 2014 – OCT 31, 2014

Affix Patient Label here

PLEASE DOCUMENT TO THE HIGHEST LEVEL OF SPECIFICITY

Type of Stroke ( √ check all that apply )

□ Ischemic / Cerebral Infarction

□ Identify the cause and site ________________________

i.e. embolism or thrombus and site of arteries (precerebral or cerebral etc.)

□ Hemorrhagic

□ Identify the artery from which bleed originated_____________________

i.e. middle cerebral, basilar artery, anterior communicating artery etc.

□ Intracerebral

□ Identify the anatomical site of the bleed__________________________

i.e. hemisphere, subcortical; hemisphere, cortical; brain stem etc.

Deficits/Sequelae - related to current admission

□ Hemiplegia

□ Dominant side

□ Non-dominant side

□ Urinary retention

□ Urinary/fecal incontinence

□ Sensory Loss

□ Neglect

□ Speech/language deficits

□ Aphasia/Dysphasia

□ Dysarthria

□ Apraxia

□ Hemianopia

□ None □ Other_____________

Co-morbidities:

□ Diabetes □ Hypertension □ Smoking □ Obesity □ Dyslipidemia

□ Other________

Interventions:

□ CT □ MRI □ Ventilation □ Percutaneous endoscopic gastrostomy (PEG)

□ Other _________________________

Prescription for Antithrombotic medication at discharge □ Yes □ No

Physician/NP Signature: _________________________ Date: ________________ (Must be signed in order for Health Records to use for coding)

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