North Staffordshire Combined Healthcare NHS Trust

DATE: NAME: UNIT NO:

IMMEDIATE ACUTE STROKE UNIT ASSESSMENT (must be done on arrival)

Ward Name Consultant DOB Date/time of arrival: Unit No

The SHO/MNP on call must check that the patient is stable, that the results of bloods and CT have been seen and documented, and that the drug chart has been done. Complete p1-5 of pathway if incomplete and initial additions. A full clerking will be done within the next working day by the ward staff.

I have alerted the SHO/MNP to the new patient Name of nurse…. …..….signature….……….Date+time….….

I have checked the patient and the pathway Name of doctor/ MNP…...signature………….Date+time……… . FOR PATIENTS ARRIVING ON THE ASU DURING WEEKENDS/BANK HOLS

Patients arriving on the ASU with this pathway will not have been reviewed by a senior doctor before transfer. During normal working days this will be done by the ward staff. Outside normal working hours patients must be reviewed by a senior doctor (SpR, consultant, staff grade) within 12 hours of arrival to confirm the diagnosis, make sure the pathway is complete, all results have been done and seen, patient is stable, and the drug chart is complete.

I have alerted the SpR/SG to the new patient Name of nurse……... .….signature…………….Date+time….….

I have checked the patient and the pathway Name of doctor……….... signature………… .Date+time……

CONSULTANT ASSESSMENT

Name ______Signature______Date and time ______DATE: NAME: UNIT NO:

DAY 1 (to midnight) Date______

Assessment Outcome and actions Variation from pathway Sign Highlight and hand over any problems and comments problems identified s

n  MEWS 6 hourly for 72 h Mews Score…………… o i t

a  BM daily x3 days If abnormal see actions on 72 hour v r

e  Urinalysis monitoring chart s b

O  CT head completed n o

i  Mobilise to best capacity  Walk independently Give reason if mobilisation t a

s  i within 6 hours ( tick Walk with supervision out of bed not done at least l i

b achieved level)  Walk with 1 once in the first 24 h o

M  Walk with 2  Transfer indep./ w 1/ w2 /hoist  Sit out of bed  Sit at the edge of bed  Sit propped up in bed  Recovery position n o

i  Discuss effects stroke, If drowsy wake patient up by sitting t a l place, time and treatments up or changing position. u m

i with patient t S  Check glasses in place/ no Adjust topic according to conscious glasses needed state, offer TV, books or music to  Check hearing aid in place / alert patients. no hearing aid needed Encourage family to contribute. s t

n  Dysphagia Assessment Refered to SALT e

m  Yes s s e

s  No s

A  Elimination Document risks identified:  Weight 1.  Nutrition 2.  MRSA screen 3.  Assessments as per 4. nursing care plan 5.

 Bilateral leg doppler ABPI L Leg……R leg………  Apply TEDs / TEDs not applied (give reason) e c  Check for catheter, remove  No catheter on arrival n e n

i catheter if present  Catheter removed t n

o  continence assessment  Cath. not removed C (give reason) Time urine passed…………… Bladder scan result………… d

n Barthel result………… a

t  Physio n e m s s

e  OT s s A

l a r r e f e R

Name ______Signature______Date and time ______DATE: NAME: UNIT NO: . u

d  Discussion with E relatives  Provide information pack

PROGRESS NOTES DAY 1 Date______HOUR 6 – 24

Time Report (all professions) Signature and professional discipline

PROGRESS NOTES DAY 1 Date______HOUR 6 – 24

DAY 2 (to midnight) Date______

Do Variation from pathway Sign. Comments and actions

MEDICAL  Review BP,Pulse,T,O2 Sats , R/R and prescribe appropriate treatment  Examine for complications (DVT, PE, Pneumonia, retention, constipation)  Review CT head scan result  ASPIRIN or alternative unless haemorrhage confirmed  Review iv/sc requirements  Check for catheter, remove if present  Review drugs (still nil by mouth?)  Review blood results  Plan discharge for minor strokes Consider need for:  U&Es for NBM  Carotid Doppler if potential candidate for endarterectomy  APTT, lupus anticoagulant, Protein C, Protein S, antithrombin III in patients <50  Echo if cardiac source of embolism suspected  VDRL/TPHA if indicated

NURSING  BP, HR, T, O2 Sats, SSS x4/d  Blood Sugar x1/d  Early Mobilisation activity record  Dysphagia screen  Elimination needs  First day meeting  Discussion with relatives  Appointment for relatives’ clinic

PHYSIO  First assessment complete  Mobilisation discussed with key nurse  Treatment started

OT  First assessment complete  Discussed with key nurse

SALT/  First assessment complete swallow  Normal swallow, no assessment needed  Not fit for assessment yet/ assess later SALT/  First assessment complete speech  No speech problem  Not fit for assessment yet/ assess later DIETITIAN  First assessment complete  Assessment not needed yet

DC Liaison  First assessment complete  Not fit for assessment yet/ assess later

SW  First assessment complete  Not fit for assessment yet/ assess later

ESD  First assessment complete  Not fit for assessment yet/ assess later

PROGRESS NOTES DAY 2 Date______

DAY 3 Date______

Do Variation from pathway Signature Comments and actions

a  Review BP,Pulse,T,O2 Sats ,R/R, neuro c i ob’s and prescribe appropriate treatment d e  Examine for complications (DVT, PE, M Pneumonia, retention, constipation)  Review iv/sc requirements  Review drugs (still nil by mouth?)  Review blood results  Update stroke checklist  Plan discharge for minor strokes  Diagnosis and plans discussed with patient/ family g

n  BP, HR, T, O2 Sats, R/R, neuro ob’s x4/d i s

r  Blood Sugar x1/d u 

N Early Mobilisation activity record  Ensure patient and family aware of diagnosis and plans  Document mood s

e  i Physiotherapy given p

a  Occupational therapy given r

e  Speech therapy given / not needed h

T  SALT swallow assessm. done/ not needed  Dietician review done/ not needed  Driving advice given/ not needed / deferred

C  DC liaison assessed / not appropriate (yet) D

g  List for rehab wd 5/ general/ n i

n intermediate care/ not fit for transfer yet n

a  Referred for ESD / not appropriate (yet) l p

VARIATION FROM PATHWAY during the first 72 hours, assessments and actions to follow later

Time Variation Action Signature

Name ______Signature______Date and time ______