STROKE CARE PATHWAY

 
   

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THE DOCTOR'S ROUTE THROUGH THE PATHWAY

In summary, the doctor writes:

  • Initial assessment notes in the red section
  • First 5 days follow-up notes in the orange section (structured forms)
  • After first 5 days, follow up in orange section (continuation sheets)
  • Weekly multidisciplinary goals in the yellow section

These documents will now be considered in detail;the pages are reproduced here and annotated in red to explain the need for the data items. There are links to other pages and sites for more detail and supporting evidence.

The doctor's initial assessment starts in the red section, on page 3.

The aims of the initial assessment are:

  • Diagnosis of the site of the lesion
  • Diagnosis of the underlying pathology (ischaemic or haemorrhagic)
  • Identification of those needing neurosurgical referral
  • Detection of risk factors for secondary prevention
  • Assessment of the effects of the stroke to allow prevention of complications & planning of rehabilitation

It is advisable to follow this learning resource using a copy of the Stroke Pathway folder, so as to familiarise yourself with the document.

Starting on page 3:


INVESTIGATIONS/DIAGNOSIS
(to be completed by a member of the A&E or medical team)

PATIENT NAME: (Attach identity sticker)You are responsible for ensuring the record relates to the correct patient. If no stickers are available at the time of admission, in addition to the patient's name you should write 2 of:-

address, hospital number, date of birth.


DATE:

TIME:

SOURCE OF HISTORY? If this is not the patient, state the relationship of the historian to the patient & the reason patient is unable to give history (eg confused; unconscious)


PRESENTING COMPLAINT: This entry is free text, but includes ONLY the immediate history of the presenting episode. Particular features of the history are required in structured form on the following page, so do not duplicate them here:

  • Drugs
  • Past Medical History
  • Family history
  • Risk Factors
  • Social history/Living arrangements

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Page 4

FAMILY HISTORY: This is particularly important in younger patients (<50yrs)

Hypertension : Y/N

MI/Angina: Y/N

Hypercholesterolaemia Y/N

RISK FACTORS: This is all important information for secondary prevention

<
Previous stroke  Y/N Atrial fibrillation   Y/N
Hypertension     Y/N

Diabetes            Y/N

MI/Angina        Y/N Hyperlipidaemia Y/N
Periph'l Vascular Disease Y/N

Smoker:   Y/N   if 'yes' , how much per day:

Alcohol:    Y/N  if 'yes', how many units per week:

PAST MEDICAL HISTORY:

Free text entry; include all major conditions & operations, apart from those mentioned above.

In particular ask about arthritis, which may compromise rehabilitation.

 

DRUGS: Free text entry, but include route & frequency

ALLERGIES:

HOME ARRANGEMENTS: Please state:

Include here whether living alone; who is carer; whether home care support; services;also occupation, if applicable and whether patient drives

 

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PHYSICAL EXAMINATION         Page 5

Communication check: This information will be used by all users of the pathway.

Vision

Good (with/without glasses) 

Poor

Blind

      

Hearing

Good

Poor

Wears aid? (if yes, R or L?)

Verbal communication

Can follow simple commands? Y/N

Able to speak?     Y/N

 

Comments

State concscious level if relevant

 

Glasgow coma score: (out of 15)     This is an important predictor of outcome.

Motor: Eyes: Verbal: Total:

Temperature:

CARDIOVASCULAR SYSTEM:

The information entered in this section will be important for secondary prevention

Pulse: Atrial fibrillation is a risk factor

Rate bpm  
Rhythm  
Volume  

BP Hypertension is a risk factor

Peripheral Pulses: If there are signs of peripheral vascular disease, TEDS are contraindicated

Carotid bruits:

Heart sounds: Valvar heart disease is a risk factor

Peripheral oedema Y/N JVP

Concomitant congestive cardiac failure increases Waterlow score and requires a variance record.

 

RESPIRATORY SYSTEM: Oxygen saturation:

 

ABDOMEN: Record urinary continence; it is an important prognostic sign for outcome of stroke.

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Page 6

NEUROLOGICAL SYSTEM

R/L Handed (please state)

 

 

CRANIAL NERVES

Comments

II       Visual Fields     

           Fundoscopy

         Pupils

  State if patient is insufficiently alert or cognitively impaired, and therefore impossible to assess.

III    

IV

VI  Eye Movements

  Record deviation of gaze. If patient is unconscious, record doll's eye movements

V       Corneal Reflex

( if appropriate)

 

VII     Facial Movement

IX,X Swallow

 

See swallow assessment

XII     Tongue

 

 

LIMBS

ARMS

 

LEGS

 

Right

Left

 

Right

Left

Tone

 

 

 

 

 

 

Shoulder Abduct

 

 

Hip Flex

 

 

Aduct

 

 

Extend

 

 

Elbow Flex

 

 

Knee flex

 

 

Extend

 

 

Extend

 

 

Wrist Flex

 

 

Dorsi Flex

 

 

Grip

 

 

Plantar Flex

 

 

Power graded out of 5 MRC Scale

 

REFLEXES

ARMS

 

 

LEGS

 

Right

Left

 

 

Right

Left

Biceps

 

 

 

Knee

 

 

Triceps

 

 

 

Ankle

 

 

Brachioradialis

(supinator)

 

 

 

Plantar

 

 

 

 

Right

Left

GROSS  SENSATION  TO  TOUCH (Y/N)

 

 

 Is there neglect             Yes/No        Sensory inattention                 Yes/No

TRUNCAL  CONTROL/GAIT Gait & movement may have to be assessed later in conjunction with physiotherapist, depending on the patient's disability.

Can the patient:

Y/N

Can the patient:

Y/N

            Lift his/her head?

 

            Stand?

 

            Sit?

 

            Walk?

 

Summary of neurological deficit : Summarising the deficit should allow you to deduce where the lesion is most likely to be

 

 

 
 

 

 

 


CLINICAL IMPRESSION This entry is free-text, allowing you to 'think aloud'. There are specific aspects of the diagnosis and management below, to be entered in a more structured format.

(to be completed by member of medical team)

DATE:                                                TIME:

Click on links below for further explanation about coding and the classification of cerebral infarcts:

               

ICD10 code/description:  (circle diagnosis)

I 61

Intra-cerebral haemorrhage

I 62

Other non-traumatic intracranial haemorrhage

I 63

Cerebral infarction:    TACI        PACI        POCI      LACI    Tick a  box

I 64

Stroke, not specified as haemorrhage or infarction

CT Scan requested           Urgent

Within 48 hrs               Not indicated

 

  Click on CT scan for guidelines about requesting urgent scan.

 

 

Plan: This should include medical treatment, whether patient may have oral intake; if not specify route for nutrition & fluids.

Plan for continence management should also be specified.

Multidisciplinary assessment is routine,but you may wish to highlight particular features for the PAMs. Finally you should specify when you will review.  

 

 

 

 

 

 

 

 

Resuscitation Status                      Review on (insert date)                  Today’s Date & Initials

1.

 

 

 

 

 

2.

 

 

 

 

 

 

If not for resuscitation night sister may verify

Sign

 

 

 

Y/N

 

Date and time

      Resuscitation status discussed with patient

     

 

 

 

 

      Resuscitation status discussed with next of kin

 

 

 

 

This completes the doctor's initial assessment.

Your next entry in this patient's file will be in the orange section, in the acute 5 day plan, click to continue your route through the pathway.

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Copyright ©Nikki Devitt 2002, on behalf of the WAHT Stroke Pathway Group

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Date of last review: 25th April 2002

Date of next review:25th October 2002