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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
__________
GREY BRUCE HEALTH NETWORK
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
GREY BRUCE HEALTH NETWORK
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL PATIENT ID
PROCESS
EMERGENCY PHASE
0 - 3 HOURS P = Done O = Not Done N/A = Not Applicable
* requires descriptive charting in progress notes
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
© 2004-2014 Grey Bruce Health Network 4Review Dec 2016
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 Page 6 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 Page 7 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 Page 8 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 Page 9 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
P = Done O = Not Done N/A = Not Applicable
* requires descriptive charting in progress notes
GREY BRUCE HEALTH NETWORK
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL PATIENT ID
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
© 2004-2014 Grey Bruce Health Network 10Review Dec 2016
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
CLINICAL PATHWAY CHECKLIST
GREY BRUCE HEALTH NETWORK
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
P = Done O = Not Done N/A = Not Applicable
* requires descriptive charting in progress notes
NG FEEDING ESTABLISHED / CLINICAL NUTRITION CONSULT
PROTOCOL INITIATED / ENTER FEEDING ORDER SET INITIATED
Updated Dec 2014
© 2004-2014 Grey Bruce Health Network 11Review Dec 2016
DISCHARGE
PLANNING
Progress Notes:
GREY BRUCE HEALTH NETWORK
STROKE
INITIALS:
* BARRIERS TO LEARNING DOCUMENTED (Patient or Family)
*SPECIFIC COMMUNICATIN / NEGLECT DEFICITS DOCUMENTED
ACUTE CARE PHASE
(Record Q4H on Checklist)
P = Done O = Not Done N/A = Not Applicable
* requires descriptive charting in progress notes
* 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
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL PATIENT ID
Updated Dec 2014
© 2004-2014 Grey Bruce Health Network 12Review Dec 2016
Progress Notes:
GREY BRUCE HEALTH NETWORK
STROKE
PATIENT ID
* CLINICAL NUTRITION
* PHARMACIST
* OTHER:
* CCAC / DISCHARGE PLANNING
* SOCIAL WORKER
CLINICAL PATHWAY CHECKLIST
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
© 2004-2014 Grey Bruce Health Network 13Review Dec 2016
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*
GREY BRUCE HEALTH NETWORK
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:
GREY BRUCE HEALTH NETWORK
CLINICAL PATHWAY
ACUTE - MEDICAL
Braden Risk Assessment
STROKE
SCORING (Key on Reverse)
-Occupational Therapy
-Activity level (i.e. turning, positioning)
Updated Dec 2014
© 2004-2014 Grey Bruce Health Network 15Review Dec 2016
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
(Record Q4H on Checklist)
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:
GREY BRUCE HEALTH NETWORK
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL
STROKE
INTERDISCIPLINARY CONSULTS
COMPLETED
PATIENT ID
DAY:
P = Done O = Not Done N/A = Not Applicable
* required descriptive charting in progress notes
PERFORMANCE
INDICATORS
q Met q Not Met q N/A
TRIAGE (TRANSITION PLAN)
COMPLETED
Updated Dec 2014
© 2004-2014 Grey Bruce Health Network 17Review Dec 2016
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:
ACUTE - MEDICAL PATIENT ID
PROCESS
DAY: DAY:
DATE:
STROKE
CLINICAL PATHWAY CHECKLIST
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
(Record Q4H on Checklist)
TRANSITIONAL PHASE
P = Done O = Not Done N/A = Not Applicable
* required descriptive charting in progress notes
GREY BRUCE HEALTH NETWORK
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
© 2004-2014 Grey Bruce Health Network 18Review Dec 2016
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
P = Done O = Not Done N/A = Not Applicable
* required descriptive charting in progress notes
REHABILITATION CONSULT DISCUSSION INITIATED
*BARRIERS TO REHABILITATION READINESS
- Plan commenced to optimize readiness / alternate plan
UPDATE AND REVIEW PLAN FOR DISCHARGE WITH
PATIENT/CAREGIVER
ACUTE - MEDICAL PATIENT ID
PROCESS
DAY: DAY: DAY:
DATE:
GREY BRUCE HEALTH NETWORK
DATE: DATE:
STROKE
(Record Q4H on Checklist)
CLINICAL PATHWAY CHECKLIST
TRANSITIONAL PHASE
Updated Dec 2014
© 2004-2014 Grey Bruce Health Network 19Review Dec 2016
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
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL
GREY BRUCE HEALTH NETWORK
*PHARMACIST
*SOCIAL WORKER
*OTHER:
PDATE &
TIMESIGNATURE
Updated Dec 2014
© 2004-2014 Grey Bruce Health Network 20Review Dec 2016
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:
GREY BRUCE HEALTH NETWORK
STROKE
CLINICAL PATHWAY CHECKLISTPATIENT ID
ACUTE - MEDICAL
PROCESS
MAINTENANCE PHASE
BEYOND DAY 6 COMPLETED
P = Done O = Not Done N/A = Not Applicable
"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
© 2004-2014 Grey Bruce Health Network 21Review Dec 2016
PSYCHOSOCIAL
SUPPORT/
EDUCATION
UPON PATIENT DISCHARGE, REFER TO PATHWAY DISCHARGE CRITERIA SHEET
INITIALS:
Progress Notes:
GREY BRUCE HEALTH NETWORK
STROKE
CLINICAL PATHWAY CHECKLISTPATIENT ID
ACUTE - MEDICAL
STROKE TEACHING ON GOING
DISCHARGE
PLANNING
PROCESS
MAINTENANCE PHASE
BEYOND DAY 6 COMPLETED
P = Done O = Not Done N/A = Not Applicable
"O" requires descriptive charting in progress notes
ASSESS DISCHARGE CRITERIA DAILY
ONGOING STRATEGY TO OVERCOME BARRIERS TO DISCHARGE IN PLACE
Updated Dec 2014
© 2004-2014 Grey Bruce Health Network 22Review Dec 2016
PROCESS INITIAL
4 DRIVING STATUS REVIEWED
5SECONDARY PREVENTION RISK
FACTORS ADDRESSED
LABORATORY /
DIAGNOSTICS
TREATMENTS/
INTERVENTIONS
NUTRITION
MOBILITY/ACTIVITY
CONSULTS
PERFORMANCE
INDICATORS
DATE MET
q Met q Not Met q N/A
q Met q Not Met q N/A
SPEECH/LANGUAGE AND/OR SWALLOWING FOLLOW UP
ARRANGED IF NEEDED
TRANSFER INFORMATION CHECKLIST COMPLETED
GREY BRUCE HEALTH NETWORK
CLINICAL PATHWAY CHECKLIST
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
© 2004-2014 Grey Bruce Health Network 23Review Dec 2016
Progress Notes:
PATIENT ID
GREY BRUCE HEALTH NETWORK
STROKE
CLINICAL PATHWAY CHECKLIST
ACUTE - MEDICAL
Updated Dec 2014
© 2004-2014 Grey Bruce Health Network 24Review Dec 2016
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)
25