Discharge Criteria - Copy with patient to receiving hospital- Original to stay on patient chart
MAR Sheet - Copy with patient to receiving hospital- Original to stay on patient chart
Anticoagulant Record - Copy with patient to receiving hospital- Original to stay on patient chart
Smiley Face Tool - Copy with patient to receiving hospital- Original to stay on patient chart
Blaylock Discharge Tool - Copy with patient to receiving hospital- Original to stay on patient chart
Physio Database - Copy with patient to receiving hospital- Original to stay on patient chart
FRACTURED HIPCLINICAL PATHWAY
Hanover and District Hospital PATIENT ID
HOW TO USE THE CLINICAL PATHWAY
This is a proactive tool to avoid delays in treatment and discharge. These are not orders, only a guide to usual orders.
INCLUSION CRITERIA
All patients who are admitted to hospital with a hip fracture for repair or replacement.
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.
PHYSICIANS: Add or delete tasks according to individual patient complexity, and initial all changes.
HEALTH CARE PROFESSIONALS: Initial tasks as completed. Place N/A and initial 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.
TRANSFER PATIENTS: if patient is transferred to another hospital in Grey-Bruce or to CCAC, send a copy of the following to site/agency:
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Sensory Perception: Ability to respond meaningfully to pressure—related discomfort
Completely Limited Very Limited Slightly
LimitedNo Impairment
Moisture: Degree to which skin is exposed to moisture
Constantly Moist Often Moist Occasionally
MoistRarely Moist
Activity: Degree of Physical Activity Bedfast Chair Fast Walks
OccasionallyWalks Frequently
Mobility: Ability to change and control body position
Completely Immobile Very Limited Slightly
LimitedNo Limitations
Nutrition: Usual food intake pattern Very Poor Probably
Inadequate Adequate Excellent
Friction and Sheer Problem Potential Problem
No Apparent Problem
LOW RISK(SCORE > 15)
Ongoing assessment for change in status related to any of the six risk areas
FRACTURED HIPCLINICAL PATHWAY
Braden Risk Assessment
Hanover and District Hospital PATIENT ID
SCORING (Key on Reverse)
SCORE
TOTAL SCORE
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)
Initiate and document plan of care on Kardex and Unit specific Progress Notes including:
Includes “Moderate Risk Intervention” plus requested referral to:
Document reassessment weekly on Kardex
-Activity level (i.e. turning, positioning) -Physiotherapy-Continence management -Occupational Therapy-Monitoring of pressure point areas -Dietitian
-Patient education re: prevention
-Monitor nutritional status-Skin care tools used: prevention mattresses or treatment (i.e. air mattresses), creams, bed hoop, trapeze, dressings
1. Constantly MoistSkin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
2. Often MoistSkin is often, but not always moist. Linen must be changed at least once a shift.
3. Occasionally MoistSkin is occasionally moist, requiring an extra linen change approximately once a day.
4. Rarely MoistSkin is usually dry, linen only requires changing at routine intervals.
Activity
Degree of physical activity
1. BedfastConfined to a bed.
2. Chair FastAbility to walk severelylimited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.
3. Walks OccasionallyWalks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.
4. Walks FrequentlyWalks 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 ImmobileDoes not make even slight changes in body or extremity position without assistance.
2. Very LimitedMakes occasional slight changes in body or extremity position, but unable to make frequent or significant changesindependently.
3. Slightly LimitedMakes frequent, though slight changes in body or extremity position independently.
4. No LimitationsMakes major and frequent changes in position without assistance.
Nutrition 1. Very PoorNever 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.ORIs on NPO and/or maintained on clear fluids or IV for more than 5 days.
2. Probably InadequateRarely 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.ORReceives less than optimum amount of liquid diet or tube feeding.
3. AdequateEats 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.ORIs on a tube feeding or TPN (Total Parenteral Nutrition) regimen, which probably meets most of nutritional needs.
4. ExcellentEats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eatsbetween meals. Does not require supplementation.
Friction and Shear
1. ProblemRequires 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 ProblemMoves 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 ProblemMoves 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 meaningfullyto pressure related discomfort
1. Completely LimitedUnresponsive (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 LimitedResponds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.ORHas a sensory impairment, which limits the ability to feel pain or discomfort over 1/2 of body.
3. Slightly LimitedResponds to verbal commands but cannot always communicate discomfort or need to be turned.ORHas some sensory Impairment, which limits ability to feel pain or discomfort in 1 or 2 extremities.
4. No ImpairmentResponds to verbal commands. Has no sensory deficit, which would limit ability to feel or voice pain or discomfort.
Today, do you, or would you have any difficulty at all with:Extreme
Difficulty/ Unable to Perform Activity
Quite a bit of Difficulty
Moderate Difficulty
A little bit of Difficulty
No Difficulty
1 0 1 2 3 4
2 0 1 2 3 4
3 0 1 2 3 44 0 1 2 3 45 0 1 2 3 46 0 1 2 3 4
7 0 1 2 3 4
8 0 1 2 3 4
9 0 1 2 3 4
10 0 1 2 3 411 0 1 2 3 412 0 1 2 3 4
13 0 1 2 3 4
14 0 1 2 3 415 0 1 2 3 416 0 1 2 3 417 0 1 2 3 4
18 0 1 2 3 4
19 0 1 2 3 420 0 1 2 3 4
Total Score /80 Goal - score of 50 by discharge from services
Making sharp turns while running fastHoppingRolling over in bed
Column Totals
Standing for 1 hourSitting for 1 hourRunning on even groundRunning on uneven ground
Getting into or out of a carWalking 2 blocksWalking a mileGoing up or down 10 stairs (about 1 flight of stairs)
SquattingLifting an object, like a bag of groceries from the floorPerforming light activities around your homePerforming heavy activities around your home
Your usual hobbies, recreational or sporting activitiesGetting into or out of the bathWalking between roomsPutting on your shoes or socks
We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for EACH activity.
(Circle one number on each line)
ActivitiesAny of your usual work, housework or school activities
PLANS FOR DISCHARGE DISCUSSED WITH PATIENT/FAMILY AND DOCUMENTED ON PROGRESS NOTESREVIEW WITH SURGEON, NOTIFY APPROPRIATE RECEIVING HOSPITAL OR UNIT OF POTENTIAL TRANSFER IF APPLICABLEBLAYLOCK DISCHARGE PLANNING RISK ASSESSMENT SCREEN REVIEWED, INFORM CCAC OF CHANGES IF APPLICABLE
ASSESS DISCHARGE CRITERIA DAILY
OTHER:
PSYCHOSOCIAL SUPPORT/
EDUCATION
REVIEW PATIENT PATHWAY
REVIEW HIP PRECAUTIONS IF HIP REPLACED
VERBALIZES UNDERSTANDING OF PLAN OF CARE
PATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POSTDISCHARGE IF APPLICABLE
Disorientation: Was the patient disoriented at any time during conversation, such as thinking that he/she was somewhere other than the hospital, using the wrong bed, or misjudging the time of day? Yes No
5. Other Clinical Descriptors that often accompany delirium:
Psychomotor Agitation (one of A or B): A) At any time, did the patient have an unusually increased level of motor activity, such as restlessness, picking at bedclothes, tapping fingers, or making frequent sudden changes in position?B) At any time, did the patient have any unusually decreased level of motor activity, such as sluggishness, staring into space, staying in one position for a long time, or moving very slowly?
Yes No
Memory Impairment: Did the patient demonstrate any memory problems during the interview, such as inability to remember events in the hospital or difficulty remembering instructions? Yes No
Perceptual Disturbance: Did the patient have any evidence of perceptual disturbance, for example hallucinations, illusions, or misinterpretations (such as thinking something was moving when it was not)? Yes No
Was patient’s thinking disorganized or incoherent, i.e. rambling/irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Yes No
4. Altered Level of Consciousness
How would you rate the patient’s level of consciousness?(positive response is any response other than Alert (normal))
to stimuli, startled easily) Lethargic (drowsy, easily aroused)
Stupor (difficult to arouse) Coma (unarousable)
Uncertain
If present or abnormal, please describe this behaviour:
If present or abnormal, did the behaviour fluctuate during the conversation, that is tend to come and go, or increase/decrease in severity?
Yes No Uncertain Not applicable
3. Disorganized Thinking
Not at any time Sometimes, in mild form
Sometimes, in marked form Uncertain
Is there evidence of an acute change in mental status from the patient’s baseline? Yes No
2. Inattention
Altered Sleep-Wake Cycle: Did the patient have evidence of disturbance of the sleep wake cycle, such as excessive daytime sleepiness with insomnia at night? Yes No
FRACTURE HIP CLINICAL PATHWAY
Confusion Assessment Method Tool
You will be able to answer the following questions after a few conversations with the patient, discussing patient behaviours with staff and family, and/or reading the chart.
Scoring: Patient diagnosed with Delirium if has a positive response to Sections 1 AND 2, as well as EITHER Sections 3 OR 4. Section 5 will help substantiate the diagnosis, but is not diagnostic criteria. If patient is diagnosed with Delirium, refer to Delirium Management Checklist, see back of page.
Hanover and District Hospital PATIENT ID
1. Acute Onset
Did the patient have difficulty focusing attention, for example being easily distractible or having difficulty keeping track of what was said?
9. Provide adequate nutrition including fluid replacement, nutritional intake
10. Enhance sleep: if conservative measures fail, a short/intermediate acting benzodiazepine, e.g. Lorazepam 0.5-1 mg
11. Manage agitation: pharmacological management may involve a small dose of typical and atypical neuroleptics and small doses of short acting benzodiazepines. Because of the risk of side effects, these medications are used only when severity of symptoms place patients and others at risk. Re-evaluate the need for these medications daily.
5. Mobilize early
6. Implement a toileting routine
7. Provide comfort measures to reduce pain, anxiety, or agitation
8. Avoid restraints (restraining a delirious patient invariably increases agitation)
b) Metabolic Imbalance: - Check for high or low levels of Sodium, Sugar, Calcium - Check for dehydration - Check for organ failure
c) Infection: - Identify and treat systemic infection, e.g. UTI, pneumonia
3. Ensure optimal sensory input: - Eyeglasses on and clean - Hearing aid working and in use - Avoid excessive stimulation, e.g. light, noise - Use night-light at night
4. Encourage: - Familiar persons to visit - Consistent staffing, preferably primary nursing - Familiar objects at bedside, e.g. pictures
If Delirium is positively identified, do the following:
1. Address immediate safety (self, others)
2. Investigate cause
a) Medications: - Review existing medications - Discontinue non-essential medications, especially analgesics, anticholinergics, sedatives
