PHILIPPINE HEART CENTER East Avenue, Quezon City DEPARTMENT OF PEDIATRIC CARDIOLOGY CHD – VENTRICULAR SEPTAL DEFECT CLINICAL PATHWAY OPEN HEART SURGERY – VSD CORRECTION INCLUSION CRITERIA: 1. Age : Age 6 months - 18 years of age (For Philhealth Z-Benefit Program : 1 - 5 years + 364 days ONLY) 2. With Ventricular Septal Defect – isolated 3. With VSD and mild Aortic Regurgitation with no need to repair or replace Aortic Valve EXCLUSION CRITERIA: 1. Associated with other types of CHD or any Acquired Heart Disease 2. With moderate to severe pulmonary hypertension warranting prolonged mechanical ventilation 3. Patients with Chromosomal abnormalities Check for the following risk factors: 1. PA Hypertension Moderate Severe but reactive in cardiac cath 2. Combined with Aortic Regurgitation + RCSOV Moderate to Severe Aortic Regurgitation 3. Combined with other Congenital or Acquired Heart Disease Yes 4. With associated Pulmonary Infection or Problem Yes Note: If (+) risk factor #1, proceed to pathway Shunts with Pulmonary Artery Hypertension If (+) risk factor #2 or 3, proceed to Complex Heart Disease Pathway If (+) risk factor #4, resolve pulmonary problem + pulmonary clearance before proceeding to VSD Pathway. PATIENT’S NAME ______________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME DATE OF BIRTH ________________ MM/DD/ YYYY SEX: ( ) M ( ) F PHILHEALTH NUMBER ______________________________ ( )Father ( )Mother Room No. HOSPITAL NUMBER DAY 1: Pathway Activated: Date:______Time:______ Pathway Terminated: Date:______Time:______ (Day 1-1) 1 CLINICAL NOTES PHYSICIAN’S ORDER SIGNATURE VARIANCE Subjective complaints/symptoms: failure to thrive frequent respiratory tract infections diaphoresis difficulty of breathing others: ________________________ ______________________________ ______________________________ Vital signs: BP HR RR Temp Ht Wt BSA BMI O 2 sat Latest Clinical Findings: Skin: __pale __pink __jaundice __cyanotic Pupils (size/reactivity): ________________ Conjunctiva (pale/pink): _______________ Chest Expansion: _____________________ Lungs (breath sounds): ________________ Heart ______________________________ ___________________________________ ___________________________________ Abdomen: __________________________ Liver edge: _______________________ Peripheral and Central pulses: __________ Extremities: Warm / cold ______________ CRT: ___ <2sec ___> 2 sec Neuro exam: Admit to room _______ under the service of: Pediatric Cardiologist: ______________________ TCVS: ___________________________________ CV Anesthesia : ___________________________ CV Intensivist: ____________________________ Pediatric Pulmonology: _____________________ Please secure consent for Admission Please accomplish PHC admitting history and PE database Monitor Vital Signs, intake, output Request for the following diagnostics: Protime (PT) > 70 %; INR < 1.5 PTT < 45 secs Bleeding Time (if platelet < 100,000) Creatinine Serum Na, K, Ca Blood Typing save blood for crossmatching Request for Introperative TEE Medications Digoxin __________________________________ Furosemide_______________________________ Captopril_________________________________ Others __________________________________ ___________________________________ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ SURGICAL ORDERS Preparation of Blood Products: Cryoprecipitate ___________________ units FWB / PRBC ______________________ units Platelet concentrate _______________ units Fresh Frozen Plasma _______________ units (Refer to Blood Conservation Program of the Hospital) A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__
Transcript
PHILIPPINE HEART CENTER East Avenue, Quezon City
DEPARTMENT OF PEDIATRIC CARDIOLOGY CHD – VENTRICULAR SEPTAL DEFECT CLINICAL PATHWAY
OPEN HEART SURGERY – VSD CORRECTION
INCLUSION CRITERIA: 1. Age : Age 6 months - 18 years of age
(For Philhealth Z-Benefit Program : 1 - 5 years + 364 days ONLY) 2. With Ventricular Septal Defect – isolated 3. With VSD and mild Aortic Regurgitation with no need to repair or replace Aortic Valve
EXCLUSION CRITERIA: 1. Associated with other types of CHD or any Acquired Heart Disease 2. With moderate to severe pulmonary hypertension warranting prolonged mechanical ventilation 3. Patients with Chromosomal abnormalities
Check for the following risk factors:
1. PA Hypertension
Moderate
Severe but reactive in cardiac cath 2. Combined with Aortic Regurgitation + RCSOV
Moderate to Severe Aortic Regurgitation
3. Combined with other Congenital or Acquired Heart Disease
Yes 4. With associated Pulmonary Infection or Problem
Yes
Note: If (+) risk factor #1, proceed to pathway Shunts with Pulmonary Artery Hypertension If (+) risk factor #2 or 3, proceed to Complex Heart Disease Pathway If (+) risk factor #4, resolve pulmonary problem + pulmonary clearance before proceeding to VSD Pathway.
PATIENT’S NAME ______________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME
DATE OF BIRTH ________________ MM/DD/ YYYY
SEX: ( ) M ( ) F
PHILHEALTH NUMBER ______________________________ ( )Father ( )Mother
Room No. HOSPITAL NUMBER
DAY 1: Pathway Activated: Date:______Time:______ Pathway Terminated: Date:______Time:______ (Day 1-1) 1 CLINICAL NOTES PHYSICIAN’S ORDER SIGNATURE VARIANCE
Admit to room _______ under the service of: Pediatric Cardiologist: ______________________ TCVS: ___________________________________ CV Anesthesia : ___________________________ CV Intensivist: ____________________________ Pediatric Pulmonology: _____________________
Please secure consent for Admission
Please accomplish PHC admitting history and PE database
Monitor Vital Signs, intake, output
Request for the following diagnostics:
Protime (PT) > 70 %; INR < 1.5 PTT < 45 secs Bleeding Time (if platelet < 100,000) Creatinine Serum Na, K, Ca Blood Typing save blood for crossmatching Request for Introperative TEE
SURGICAL ORDERS Preparation of Blood Products: Cryoprecipitate ___________________ units FWB / PRBC ______________________ units Platelet concentrate _______________ units Fresh Frozen Plasma _______________ units (Refer to Blood Conservation Program of the Hospital)
PATIENT’S NAME ___________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME
DATE OF BIRTH ________________ MM/DD/ YYYY
SEX: ( ) M ( ) F
PHILHEALTH NUMBER _____________________________ ( )Father ( )Mother
Room No. HOSPITAL NUMBER
DAY 1: Date: ___________________________________Time:____________ (Day 1- 2) 2 CLINICAL NOTES PHYSICIAN’S ORDER SIGNATURE VARIANCE
Cardiac Catheterization (Hemodynamic Study Data and Angiogrography ) No
Yes (if yes fill up succeeding data)
Date Done: _____________________
A. Diagnosis : ________________________________ ________________________________ ________________________________ B. Angiogram : 1. Good capillary Blush ( ) Y ( ) N 2. Other Associated Lesions ____________________________ ____________________________
Refer to other subspecialty services (if needed indicate specialty and name of specialist):
a. ______________________________________ b. ______________________________________ c. ______________________________________ (Please use separate referral form for additional orders of the specialist)
A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__
Diet/Nutrition:_______________________________
Activity/Safety (See nursing safety protocol/Fall prevention protocol)
Provide Psychosocial/Spiritual support to: Play therapy appropriate for age Inquire about the need for psychological evaluation
(CHEERS protocol) Inquire about spiritual need (if needed)
Patient/Family Education: Disease process Explain procedure and get consent for surgery and
blood transfusion Discuss Clinical Pathway
PARENTS/GUARDIAN UNDERSTOOD, VERBALIZED, CONSENTED AND SIGNED THE VSD CARE PLAN ( ) Yes ( ) No
A__ B__ C__ D__
A__ B__ C__ D__
A__ B__ C__ D__ A__ B__ C__ D__
A__ B__ C__ D__
A__ B__ C__ D__ A__ B__ C__ D__
A__ B__ C__ D__
A__ B__ C__ D__
NURSING ASSESSMENT: Braden Risk Score: ____________ General Pain Assessment: ___ ________ NIPS – FACES: ____________ Fall Risk Score:
____________
INTERPRETATION:
OUTCOME GOALS:
Vital signs stable
Blood products available
Pathway and procedures clear to parents/guardian
Risk of surgery explained to parent/guardian and understood
Consent for VSD correction signed
( ) Y ( ) N ( ) Y ( ) N ( ) y ( ) N ( ) Y ( ) N ( ) Y ( ) N
A__ B__ C__ D__ A__ B__ C__ D__
A__ B__ C__ D__
A__ B__ C__ D__ A__ B__ C__ D__
DISCHARGE PLANNING: Estimated date of discharge ____________ Prepare for VSD Correction Defer VSD Closure
A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__
ACTIVATED BY: ACKNOWLEDGED BY:
_______________________ Signature over Printed Name PEDIA CARDIO CONSULTANT/FELLOW Date:________Time:______
________________________ Signature over Printed Name TCVS CONSULTANT/FELLOW Date:_________Time:______
____________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (AM shift) Date:_________Time_______
_______________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (PM shift) Date:_________Time_______
VARIANCE CODES (SEE PAGE 5)
PHILIPPINE HEART CENTER East Avenue, Quezon City
DEPARTMENT OF PEDIATRIC CARDIOLOGY CHD – VENTRICULAR SEPTAL DEFECT CLINICAL PATHWAY
OPEN HEART SURGERY – VSD CORRECTION PATIENT’S NAME ___________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME
DATE OF BIRTH ________________ MM/DD/ YYYY
SEX: ( ) M ( ) F
PHILHEALTH NUMBER ___________________________ ( )Father ( )Mother
Monitor vital signs, intake and output every ___ hours
Accomplish Pre-Operative Nursing Checklist
Follow up the following laboratory results: Chest X-ray (PA-L) (AP-L) 15-lead EKG 2D Echocardiogram with CFDS CBC with platelet Protime (PT) > 70 %; INR < 1.5 PTT (< 45 secs) Bleeding Time (if platelet is < 100,000) Creatinine Serum Na, K, Ca Blood Typing (save blood for crossmatching)
Check availability of the blood products Cryoprecipitate ______ units FWB / PRBC ______ units Platelet concentrate ______ units Fresh Frozen Plasma ______ units
Activity/Safety (See nursing safety protocol/Fall prevention protocol) ______________________________________ PREOPERATIVE ASSESSMENT Provide Psychosocial/Spiritual support to: Inquire about the need for psychological evaluation
(CHEERS protocol) Inquire about spiritual need (if needed)
A___B___C___D__
A___B___C___D__
A___B___C___D__
PATIENT’S NAME ____________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME
DATE OF BIRTH ________________ MM/DD/ YYYY
SEX: ( ) M ( ) F
PHILHEALTH NUMBER ___________________________ ( )Father ( )Mother
Room No. HOSPITAL NUMBER
DAY 2: DATE______________________________TIME____________ (Day 2-3) 5
Explain procedure and get consent for surgery and blood transfusion
Discuss Clinical Pathway
Pre-operative Orientation (c/o OR/SICU Personnel) to Patient / Parents and / or significant family members
Health Education: Utilizing Methods by Nurses PARENTS/GUARDIAN UNDERSTOOD, VERBALIZED,
CONSENTED AND SIGNED THE VSD CARE PLAN ( ) Yes ( ) No
Proceed with surgery on ____________
A___B___C___D__ A___B___C___D__
A___B___C___D__ A___B___C___D__
A___B___C___D__
A___B___C___D__
A___B___C___D__
NURSING ASSESSMENT: Braden Risk Score: _________ General Pain Assessment: _________ NIPS – FACES: _________ Fall Risk Score: _________
INTERPRETATION:
OUTCOME GOALS:
Vital signs stable
Blood products available
Pathway and procedures clear to parents and/or guardian
Risk of surgery explained to parent/guardian and understood
Consent for VSD Closure signed
( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N ( ) y ( ) N ( ) Y ( ) N
A___B___C___D__ A___B___C___D__
A___B___C___D__
A___B___C___D__ A___B___C___D__
DISCHARGE PLANNING: Estimated date of discharge ____________ Prepare for VSD Correction Defer VSD surgery
A___B___C___D__ A___B___C___D__ A___B___C___D__
ACTIVATED BY: ACKNOWLEDGED BY:
_______________________ Signature over Printed Name PEDIA CARDIO CONSULTANT/FELLOW Date:_________Time:______
_________________________ Signature over Printed Name ANESTHESIA CONSULTANT/FELLOW Date:_________Time:______
____________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (AM shift) Date:_________Time_______
_______________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (AM shift) Date:_________Time_______
VARIANCE CODES A. PATIENT / FAMILY B. HEATH PROVIDER C. PHC SYSTEMS D. OUTSIDE PHC
1. Patient’s medical condition 1.Medical order 1. Results / Date availability 1. Condition / Transportation
2.Patient/Family decision 2. Provider’s decision 2. Delay in Test Results 2. Home care availability
3. Patient/ Family availability 3. Provider’s response 3. Delay in procedure 3. Other reasons
4. Noncompliance to treatment 4. Other reasons 4. Cancellation of procedures
5. No funds 5. Delay in patient transfer
6. Other reasons 6. Supplies / Equipment needed
7. Appointment / Availability
8. Weekend / Holiday
9. Other reasons
PHILIPPINE HEART CENTER East Avenue, Quezon City
DEPARTMENT OF PEDIATRIC CARDIOLOGY CHD – VENTRICULAR SEPTAL DEFECT CLINICAL PATHWAY
OPEN HEART SURGERY – VSD CORRECTION PATIENT’S NAME ____________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME
DATE OF BIRTH ________________ MM/DD/ YYYY
SEX: ( ) M ( ) F
PHILHEALTH NUMBER __________________________ ( )Father ( )Mother
Room No. HOSPITAL NUMBER
DAY 3: OR DAY Pathway Activated: Date:______Time:______ Pathway Terminated: Date:______Time:______(Day 3-1) 6
1st 8 HOURS POST SURGERY CLINICAL NOTES PHYSICIAN’S ORDER SIGNATURE VARIANCE
Date of Surgery : ____________________ Surgeon and Anesthesia Notes Total Ischemic Time: ___________________ Total Bypass Time : ____________________ Total length of procedure:_______________ Intraop Findings / Events:
Intraoperative Condition:
OFF BYPASS
Prior to transport
VITAL SIGNS / PE
BP (S/D)VP
HR
CVP
PAP
LAP
RVP
Temp
U.O
Pupils
Skin
Lung Comp
Bleeding
Medications
Dopamine
Dobutamine
Epinephrine
Milrinone
Levophed
NTG
Ca Gluc
Iloprost
Salbutamol
Labs
Hct
Na
K
Ca
ACT
ABG
Blood Transfusions
PRBC
FWB
PLT Conc
FFP
Cryo Ppt
PROCEDURE/S DONE :_______________________ _________________________________________ ADMIT TO SURGICAL ICU Monitor vital signs and review of systems every 15
minutes for the first two hours then every 30 minutes for 2 hours then hourly thereafter
Maintain the following VS: BP: ______ CR and rhythm: _______ RR: ______ O2 sat:______ Temp: _____
Hook to Capnograph Hook on temperature regulatory device if
Check parameters for re-exploration : Total Blood Volume for age: wt : __ x 80 cc /kg = ____ Any of the following: > 15% of TBV for weight per hour 10-20cc/kg/hr More than 10cc/kg/hr for successive 3 hours More than 30 cc/kg bleeding at any one time
Check Nutrition NPO while intubated Start soft diet 4 hours after extubation Progress to regular diet for age
Criteria for TRANS-OUT FROM SICU to PICU : No risk for cardiac tamponade Without indication for re-exploration of mediastinum or re-operation If the patient is unable to transfer after day
Check Physical Activity Complete Bed rest or as ordered Elevate head of bed to at least 30 degrees Patient demonstrates a daily increase in activity
level
Provide Psychological support to family :
Explain to the patient and family Risks/ Complications involved Duration of PICU stay Transfer to room and duration of hospital stay Explanation of prognosis Importance of Ambulation and increased activity Plan of Care
Monitor Vital signs, input, output Request for the following diagnostics: ABG, lactate and Serum electrolytes CBC with platelet count PT, PTT CXR portable
OXYGEN Support : If extubated:
Room air Face mask with reservoir at 4-6LPM Nasal cannula at 2-3 LPM
If still intubated (see Pulmonology Referral Sheet): Ventilatory Support :
FiO2: RR
TV / PIP PEEP
Check : Parameters for weaning from Mechanical Ventilation/Extubation/ O2 support Awake with stimulation Adequate reversal of anaesthesia Core temperature > 35.5 C Hemodynamic stability ABG : at FiO2 50%, pO2 > 75 torr ABG pCO2 <45 pH 7.35-7.50 Tolerates further weaning to FiO2 30% at SIMV
or Spontaneous mode With O2 saturation > 95% , no hypotension
Check Nutrition : NPO while intubated Start soft diet 4 hours after extubation Progress to regular diet for age
Criteria for TRANS-OUT FROM SICU to PICU : No risk for cardiac tamponade Without indication for re-exploration of
mediastinum or re-operation If the patient is unable to transfer after day 2,
specify reason : _____________________
Check Physical Activity : Complete Bed rest or as ordered Elevate head of bed to at least 30 degrees Patient demonstrates a daily increase in activity
level
Provide Psychological support to family : Explain to the patient and family Risks/ Complications involved Duration of PICU stay Transfer to room and duration of hospital stay Explanation of prognosis Importance of Ambulation and increased activity Plan of Care
Check parameters for TRANS-OUT FROM PICU TO REGULAR ROOM:
Stable vital signs > 24 hours after extubation No cardiac supports Wean supports to at least 5 ug/kg/min Tolerates feeding
If the patient cannot be transferred to regular room after day 6, specify reason : ________________________________________ Check Parameters for Extubation in Prolonged Ventilation (after 72 hours) :
Comfortable breathing pattern without diaphoresis, agitation/ anxiety, RR < 30/min
Adequate mental status to protect airway, able initiate cough
Hemodynamic stability with no vasoactive drugs Satisfactory ABG Reason if the patient cannot be extubated after
day 3 post-op ___________________________
Total Fluid Requirement : After day 3 Postop : Adjust accordingly to 1500- 1700 cc/BSA
and ad libitum with priority for oral fluids ____ cc/day
Oral Intake _________________________ cc/day
IVF Rate ____________________________ cc/hr
Cardiac Support (dose:concentration) Dopamine: (____:______) _____________ cc/hr Others:
TOTAL Rate: ___________________________ cc/hr Continue weaning from IV Inotropic support and
discontinue if the patient demonstrate the following:
BP > 90 mmHg for at least 12 hours Urine output > 1cc/kg/hr Warm extremities with CRT < 2sec If with inotropic support > 48 hrs or after day 5, specify reason :
_______________________________________
Accomplish Medication Reconciliation Form (MRF) Shift as necessary to oral medications : Digoxin : _________________________________ Diuretic : _________________________________ Vasodilator : ______________________________ Antibiotic: ________________________________ Others : __________________________________
Check parameters for chest tube removal Chest tube drainage <100 ml x 8h If CT removal after day 3, Specify reason :
________________________________
Check Nutrition Start Feeding Regular diet for age Encourage Physical Activity Complete Bed rest or as ordered Elevate head of bed to at least 30 degrees Patient demonstrates a daily increase in
activity level Refer to PEDIA Cardiac Rehab (Pedia Care)
after day 3 or earlier : _________________________________ _________________________________
Provide Psychological support to family :
Explain to the patient and family Duration of PICU stay Transfer to room and duration of hospital stay Explanation of prognosis Importance of Ambulation and increased
Lab / Ancillary Request CBC with platelet count CXR portable Others __________________________ Check parameters for TRANS-OUT FROM PICU
TO REGULAR ROOM: Stable vital signs > 24 hours after extubation No cardiac supports Wean supports to at least 5 ug/kg/min Tolerates feeding
If the patient cannot be transferred to regular room after day 6, specify reason : ________________________________________ ________________________________________
Parameters for Extubation in Prolonged Ventilation (after 72 hours) Comfortable breathing pattern without
diaphoresis, agitation/ anxiety, RR < 30/min Adequate mental status to protect airway, able
initiate cough Hemodynamic stability with no vasoactive
drugs Satisfactory ABG Reason if the patient cannot be extubated after
day 3 post-op ___________________________ Total Fluid Requirement :
After day 3 Postop: Adjust accordingly to 1500- 1700 cc/BSA and ad libitum with priorit for oral fluids ________________________ cc/day
Cardiac Support (dose:concentration) Dopamine: (____:______) ___________ cc/hr Medication Line____________________ cc/hr
TOTAL Rate: _________________________ cc/hr
Continue weaning from IV Inotropic support and discontinue if the patient demonstrates the following : BP > 90 mmHg for at least 12 hours Urine output > 1cc/kg/hr Warm extremities with CRT < 2sec If with inotropic support > 48 hrs or after day 5, specify reason : ______________________________________
Encourage Physical Activity Complete Bed rest or as ordered Elevate head of bed to at least 30 degrees Patient demonstrates a daily increase in activity
level Refer to PEDIA Cardiac Rehab (Pedia Care)
after day 3 _________________________________ _________________________________
Provide Psychological support to family :
Explain to the patient and family Duration of PICU stay Transfer to room and duration of hospital stay Explanation of prognosis Importance of Ambulation and increased
Check parameters for TRANS-OUT FROM PICU TO REGULAR ROOM:
Stable vital signs > 24 hours after extubation No cardiac supports Wean supports to at least 5 ug/kg Tolerates feeding
If the patient cannot be transferred to regular room after day 6, specify reason : ________________________________________ ________________________________________
Parameters for Extubation in Prolonged Ventilation (after 72 hours)
Comfortable breathing pattern without diaphoresis, agitation/ anxiety, RR < 30/min
Adequate mental status to protect airway, initiate cough
Hemodynamic stability with no vasoactive drugs Satisfactory ABG Reason if the patient cannot be extubated after
day 5 ___________________________
Total Fluid Requirement : Adjust accordingly to 1500- 1700 cc/BSA and ad
libitum with priority for oral fluids _____ cc/day Oral Intake __________________________ cc/day IVF Rate ______________________________cc/hr
Cardiac Support (dose:concentration) Dopamine: (____:______) _____________ cc/hr Medication Line______________________ cc/hr
TOTAL Rate: ___________________________ cc/hr
Continue weaning from IV Inotropic support and discontinue if the patient demonstrates the following: BP > 90 mmHg for at least 12 hours Urine output > 1cc/kg/hr Warm extremities with CRT < 2sec If with inotropic support > 48 hrs or after day 5,
Check Nutrition Start Feeding Regular diet for age Dietary Referral
Encourage Physical Activity Complete Bed rest or as ordered Elevate head of bed to at least 30 degrees Patient demonstrates a daily increase in activity
level Refer to PEDIA Cardiac Rehab (Pedia Care)
after day 3 ________________________________________ ________________________________________
Provide Psychological support to family :
Explain to the patient and family Duration of PICU stay Transfer to room and duration of hospital stay Explanation of prognosis Importance of Ambulation and increased
Provide Psychological support to family : Explain to the patient and family Explanation of prognosis Importance of Ambulation and increased activity Plan of Care Discharge plans
