Solved: Clinical pathway for patient admitted from ER to ICU

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Case study about critical case (adult ) respiratory problem (you can choose any critical respiratory disease )
– detils for the patient and case diagnosis
– overview of disease
-pathway
Form admission the
first few hours 0-3
3-6
6-18
Until discharge
Better pic and word of details of
Clinical pathway
– bandel
-nursing care plan
Evidence. i attach some folder for that , but this not ideal not taken the full mark i want better more that this folder
Requirements: 10
Faculty Of Applied Medical Science Department Of Msc In Medical Surgical Nursing Nurs711: Advanced Medical Surgical Nursing (Lab Section ) Clinical Pathway about Case Study On Ischemic Stroke Prepared By : Ms.Khulud A. Almansour Under Supervision Of Dr. Nagwa Ibrahim Abbas Process ER Admission ( 1 – 3 Hours ) Date & Time 12-10-2021 @ 1123 AM Assessment Physical Exam : • Temperature 36.5 degree Celsius; RR 20 bpm; PR 96 bpm; BP 103/68 mmHg • Neurological examination : E4V5M6 (GCS 15/15) Investigation : • Chest X-ray: There is no recent pulmonary infiltration or pleural effusion, Heart size is not enlarged • ECG: Normal sinus rhythm Laboratories: 12-10-2021 @ 1210 PM • PT 11.8; INR 0.95 • Blood Sugar: 98 • BUN: 20; Creatinine: 1.19 • Serum Electrolyte: (Na: 138.6; K: 3.09; Cl: 103) • CBC: (Hct: 41.8; Plt: 125, 000; WBC: 16, 400) • UA: (WBC: 20-30; RBC: 10-20; Bac:1+) Consultation Hematology consultation for blood coagulation therapy . Line & Medication IV canulla 20#G on right hand , 0.9%NSS 1 L @ 80 ml/hr on going . Activity Patient able to do ADLs with some limitation after the left side weakness , need walker . Diet Therapy Salt , Fat free diet . Nursing Intervention Nursing diagnosis : Ineffective Cerebral Tissue Perfusion related to stroke . Goal : Patient will maintain usual level of consciousness, cognition, and motor/sensory function immediately .
Nursing Interventions  Administer supplemental oxygen as indicated.  Close neurological monitoring including LOC, GSC, Seizure, etc  Monitor VS especially BP, pupillary reaction  Assess factors related to decreased cerebral perfusion and the potential for increased intracranial pressure (ICP).  Monitor heart rate and rhythm, assess for murmurs.  Monitor respirations, noting patterns and rhythm, Cheyne-Stokes respiration.  Provide bedrest, flat on bed  Provide a relaxing environment Process CT Scan ( 30min) Date & Time 12-10-2021 @ 1230 PM Assessment Patient condition still the same and stable. Investigation : • CT-Scan : Pre – rT-PA: Recent small infarction or artifact at the right-sided pons . Consultation Still to be seen by hematologist . Line & Medication IV canulla 20#G on right hand , 0.9%NSS 1 L @ 80 ml/hr on going . Activity Patient able to do ADLs with some limitation after the left side weakness , need walker . Diet Therapy Salt , Fat free diet . Nursing Intervention Nursing diagnosis : Impaired Physical Mobility related to left side weakness . Goal : Patient will maintain/increase strength and function of left side of the body within course treatment . Nursing Interventions  Assess the extent of impairment initially and functional ability.  Observe the affected side for color, edema, or other signs of compromised circulation.  Place a pillow under the axilla to abduct the arm.  Prop extremities in functional position; use footboard during moving to the CT scan bed .  Maintain a neutral position of the head.  Assist and support the patient during transmission and movement . Evaluation : Body Physical Mobility is maintained well .
Process Male Medical Ward ( 1-4 days ) Date & Time (DAY 1 ) 12-10-2021 @ 1300 PM Assessment Physical Exam : • Temperature 36.3 degree Celsius; RR 18 bpm; PR 91 bpm; BP 117/72 mmHg • Neurological examination : E4V5M6 (GCS 15/15) • Motor power : Right side (U and L E) grade 5; Left side (U and L E) grade 4 • Braden Scale : 18 • Fall scale: 3 • Modified Rankin scale: 3 • Dysphagia Screening Test : Pass Investigation : Laboratories: • Lipid Profile: (Chol: 153; Trigly: 77; HDL: 48; LDL: 82) • Blood Sugar: 96 • VDRL: Non-reactive • HbA1c: 6.1 Consultation seen by hematologist : order for Coagulation therapy to be started based on the protocol . Line & Medication IV canulla 20#G on right hand : IVrTPA 61 mg 10% rTPA 6 mg IV bolus in 1-2 mins (13.01 PM) then 90% rTPA 55 mg IB drip in 60 mins (13.02 PM ). 0.9%NSS 1 L @ 80 ml/hr Omeprazole 40 mg IV OD Cefriaxone 3.2 gms IV OD Activity Patient able to do ADLs with some limitation after the left side weakness , need walker (Modified Rankin scale: 3). Diet Therapy Salt , Fat free diet . Nursing Intervention Nursing Responsibilities for medication Administration : • Check patency of IV line . • Monitor for sigh of bleeding or worsening of condition . • Follow appropriate hospital protocol in proper administration. •Monitor fever progression. Nursing diagnosis : Risk for Bleeding related to TPA medications . prevent bleeding and recognizes signs of bleeding that need to be reported immediately with TPA medication and during all the course .
Nursing Interventions  Monitor client during rTPA therapy  Determine the patient’s health history for signs that can be associated with a risk for bleeding such as liver disease, inflammatory bowel disease, or peptic ulcer disease.  Monitor patient’s vital signs, especially BP and HR. Look for signs of orthostatic hypotension.  Review laboratory results for coagulation status as appropriate: platelet count, prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), fibrinogen, bleeding time, fibrin degradation products, vitamin K, activated coagulation time (ACT).  Check stool (guaiac) and urine (Hemastix) for occult blood.  Assess skin and mucous membranes for signs of petechiae, bruising, hematoma formation, or oozing of blood.  Monitor hematocrit (Hct) and hemoglobin (Hgb). Evaluation : No incident of bleeding within hospital stay . No intracranial bleeding on CT Scan. Date & Time (DAY 2 ) 13-10-2021 @ 0700AM Assessment • Temperature 38.2 degree Celsius; RR 22 bpm; PR 102 bpm; BP 122/82 mmHg • Neurological examination : E4V5M6 (GCS 15/15) Investigation • Post – rT-PA CTscan Done : 09:51 AM • No progressive infarction at Rt.putamen and no acute hemorrhage are noted after administration of rTPA . Laboratories: Repeated at 1130 AM ( still WBCs is high ) Consultation — Line & Medication Fever is noted , paracetamol 1g STAT IV given @ 0705 AM . Paracetamol 500mg PRN ( is added to prescription ) . 0.9%NSS 1 L @ 80 ml/hr Omeprazole 40 mg IV OD Cefriaxone 3.2 gms IV OD Clopidogrel 75 mg OD Simvastin 40 mg OD HS Doxazosin 1mg HS Activity Patient able to do ADLs with some limitation after the left side weakness , need walker (Modified Rankin scale: 3). Diet Therapy Keep NPO . Nursing Intervention Nursing diagnosis : Hyperthermia related to stroke .
Goal : Patient maintains body temperature below 38° C immediately . Nursing Interventions  Assess for signs of hyperthermia.  Administer antipyretic medications as prescribe .  Monitor the patient’s heart rate and blood pressure.  Identify the triggering factors for hyperthermia and review the client’s history, diagnosis, or procedures.  Accurately measure and document the client’s temperature every hour or as frequently as indicated, or when there is a change in the client’s condition.  Provide a tepid bath or sponge bath.  Monitor fluid intake and urine output.  Adjust and monitor environmental factors like room temperature and bed linens as indicated. Evaluation : Goal is met , Temperature is decreased 37.2oc . Date & Time (DAY 3 ) 14-10-2021 @ 0900AM Assessment • Temperature 37.2 degree Celsius; RR 16 bpm; PR 98 bpm; BP 109/77 mmHg • Neurological examination : E4V5M6 (GCS 15/15) Investigation Laboratories: • UA: (WBC: 1-2; RBC: 1-2; Bac: – ) . • Urine C/S: E. coli ESBL. Consultation Consult and refer the patient to a speech therapist. Line & Medication Paracetamol 500mg PRN 0.9%NSS 1 L @ 80 ml/hr ( DC) Omeprazole 40 mg IV OD Cefriaxone 3.2 gms IV OD Clopidogrel 75 mg OD Simvastin 40 mg OD HS Doxazosin 1mg HS Folic Acid 1 tab OD (ADD) Activity Patient able to do ADLs with some limitation after the left side weakness , need walker (Modified Rankin scale: 3). Diet Therapy Low Salt , Fat free diet . Nursing Intervention Nursing diagnosis : Impaired Verbal Communication related to neuromuscular impairment, loss of facial/oral muscle tone Goal :  Patient will indicate an understanding of the communication problems (within 1-2 days )  Patient will establish method of communication in which needs can be expressed ( within 1-2 days ) .
Nursing Interventions  Differentiate aphasia from dysarthria: speech disturbances has been noted is Dysarthria .  Ask the patient to follow simple commands (“Close and open your eyes,” “Raise your hand”); repeat simple words or sentences.  Point to objects and ask the patient to name them.  Listen for errors in conversation and provide feedback.  Write a notice at the nurses’ station and patient’s room about speech impairment. Provide a special call bell that can be activated by minimal pressure if necessary. Anticipate and provide for the patient’s needs.  Provide alternative methods of communication.  Speak in normal tones and avoid talking too fast. Give the patient ample time to respond. Evaluation : Patient is indicate an understanding of the communication problems and establishing communication in which needs can be expressed immediately . Process Discharge To Home Date & Time (DAY 4 ) 15-10-2021 @ 0844AM Assessment Diagnosis: Ischemic Attack • Temperature 37.2 degree Celsius; RR 16 bpm; PR 98 bpm; BP 109/77 mmHg • Neurological examination : E4V5M6 (GCS 15/15) Investigation CTscan : • No progressive infarction at Rt.putamen and no acute hemorrhage are noted after administration of rTPA . Laboratories: Results Within normal . Consultation OPD need for follow up as advised by physician after 2 weeks – Medical Clinic . OPD follow up Hematology clinic after 2 weeks . Physiotherapy once weekly . OPD follow up Speech therapy clinic after 1 month . Line & Medication Discharge Medication : Paracetamol (500mg) 1 tab oral PRN – Take with full stomach Clopidogrel 75 mg OD Augmentin 1grmq 12hrs – Take with full stomach Lansoprazole FDT 1 tab OD – Take before meal Folic Acid 1 tab OD – Take before meal Activity Patient able to do ADLs with some limitation after the left side weakness , need walker (Modified Rankin scale: 3). Environment: Prevent Injury Modify home to promote safety such as on slipping floor ‘ installation of side rails to normal bed and hand rails to toilet.
Diet Therapy Low Salt, low fat, fiber rich Encourage family members to prepare foods as mentioned above to control BP, Dyslipidemia and promote bowel movement. Nursing Intervention  Rehabilitation Emphasize need for continued home exercise (ROM exercise) and follow up with physiotherapist. Encourage family to provide emotional support.  Prevention and Lifestyle Modification Focus on teaching family members FAST algorithm. Promote family involvement in patient care.  Educate family to remain sensitive to patient’s reactions and needs and responding to them in an appropriate manner; treat the patient as an adult. Patient left to Home @ 1220PM .
Student name: amrah alhileesi SUPREVISOR BY : DR NAJWA Clinical pathway for ischemic stroke ADVANCE MEDICAL SURGICAL LAB
< 220/120 <185/110 3hr 0hr 0 Emergency phase 0-3  Assess of ABC vital signs –  Provide oxygen if hypoxemic  Obtain IV access  Check blood sugar, treat if need  Preform neurologic screening assessment and assess by GCS Check for BP Thrombolytic Diagnostic laboratory Mobility/Activity Psychosocial support /education CT scan ECG Blood work bed rest 1-Inform patient and family of diagnosis 2-Address immediate concerns
3hr 24hr Diagnostic laboratory Mobility/Activity positionnigpp Psychosocial support /education Pain assessment Chest assessment Monitor intak and output Monitor bowel and bladder routine Assess for DVT Braden risk assessment Falls risk assessment Neuralgic assessment Raise head of bed to 30-60 degrees Review patient pathway Family support determined Blood works Echocardiogram if order Chest x-ray Discharge planning Assess breadiness for rehab using referral form Assess needs for discharge Assessment and observations measurement Nutrition Diet as per dysphagia screening tool Consults Physiotherapy Occupational therapy Pharmacist Social worker
2day 1day Psychosocial support /education Mobility/Activity Diagnostic laboratory DVT assessment and braden Falls risk assessment Chest assessment Pain assessment Monitor intake and output Monitor bowel and bladder neurologic scale assessment risk assessment Blood work as order Up in chair with ted stockings or SCD Head up 30-60 degree Review patient pathway Family support determined Assessment and observations measurement Nutrition Diet as per dysphagia screening tool Consults If needed only Discharge planning Assess breadiness for rehab using referral form Assess needs of discharge Assess discharge criteria daily Discharge goals discussed with patient and family
Day2 to day3 Assessment and observations measurement Nutrition Psychosocial support /education Mobility/Activity Diagnostic laboratory DVT assessment and braden Falls risk assessment Chest assessment Pain assessment Monitor intake and output Monitor bowel and bladder neurologic scale assessment risk assessment Blood work as order Up in chair with ted stockings or SCD Activity as tolerated reviewed daily Ambulation’s Review patient pathway Address any question to patent and family Diet as per dysphagia screening tool Discharge planning Assess needs of discharge Assess discharge criteria daily Discharge goals discussed with patient and family
day3-day5 Psychosocial support /education Mobility/Activity Diagnostic laboratory Nutrition Diet as per dysphagia screening tool Assessment and observations measurement Discharge planning Update and review discharge plan Assistive device arranged Home program develop Assess discharge criteria daily Blood work as order Using positioning to maintain proper body alignment Ambulation’s Document tolerated siting time daily Review patient pathway Address any question to patent and family Review patient risk factor Chest assessment Pain assessment Monitor intake and output Monitor bowel and bladder neurologic scale assessment risk assessment DVT assessment and braden Falls risk assessment
discharge criteria Skin integrity plan Speech\language and \or swallowing follow up arranged if needed Consults All consult completed Psychosocial support /education Mobility/Activity Diagnostic laboratory Discharge planning Patent and family are aware of follow up appointment Discharge plan completed Follow up outpatient therapy as appropriate Out patient blood work arranged Patient is safe immobility and activities od daily living Appropriate aids if required Safety education for patient and family Patient awer of risk factors and management Patent and family have understand od stroke eductions Nutrition Patient receives adequate nutrition and appropriate hydration Consulted dietitian
Student name: ZAHRA HADI SUPREVISOR BY : DR NAJWA ID S2215009563 Clinical pathway for ischemic stroke ADVANCE MEDICAL SURGICAL LAB
< 220/120 <185/110 3hr 0hr 0 Emergency phase 0-3  Assess of ABC vital signs –  Provide oxygen if hypoxemic  Obtain IV access  Check blood sugar, treat if need  Preform neurologic screening assessment and assess by GCS Check for BP Thrombolytic Diagnostic laboratory Mobility/Activity Psychosocial support /education CT scan ECG Blood work bed rest 1-Inform patient and family of diagnosis 2-Address immediate concerns
3hr 24hr Diagnostic laboratory Mobility/Activity positionnigpp Psychosocial support /education Pain assessment Chest assessment Monitor intak and output Monitor bowel and bladder routine Assess for DVT Braden risk assessment Falls risk assessment Neuralgic assessment Raise head of bed to 30-60 degrees Review patient pathway Family support determined Blood works Echocardiogram if order Chest x-ray Discharge planning Assess breadiness for rehab using referral form Assess needs for discharge Assessment and observations measurement Nutrition Diet as per dysphagia screening tool Consults Physiotherapy Occupational therapy Pharmacist Social worker
2day 1day Psychosocial support /education Mobility/Activity Diagnostic laboratory DVT assessment and braden Falls risk assessment Chest assessment Pain assessment Monitor intake and output Monitor bowel and bladder neurologic scale assessment risk assessment Blood work as order Up in chair with ted stockings or SCD Head up 30-60 degree Review patient pathway Family support determined Assessment and observations measurement Nutrition Diet as per dysphagia screening tool Consults If needed only Discharge planning Assess breadiness for rehab using referral form Assess needs of discharge Assess discharge criteria daily Discharge goals discussed with patient and family
Day2 to day3 Assessment and observations measurement Nutrition Psychosocial support /education Mobility/Activity Diagnostic laboratory DVT assessment and braden Falls risk assessment Chest assessment Pain assessment Monitor intake and output Monitor bowel and bladder neurologic scale assessment risk assessment Blood work as order Up in chair with ted stockings or SCD Activity as tolerated reviewed daily Ambulation’s Review patient pathway Address any question to patent and family Diet as per dysphagia screening tool Discharge planning Assess needs of discharge Assess discharge criteria daily Discharge goals discussed with patient and family
day3-day5 Psychosocial support /education Mobility/Activity Diagnostic laboratory Nutrition Diet as per dysphagia screening tool Assessment and observations measurement Discharge planning Update and review discharge plan Assistive device arranged Home program develop Assess discharge criteria daily Blood work as order Using positioning to maintain proper body alignment Ambulation’s Document tolerated siting time daily Review patient pathway Address any question to patent and family Review patient risk factor Chest assessment Pain assessment Monitor intake and output Monitor bowel and bladder neurologic scale assessment risk assessment DVT assessment and braden Falls risk assessment
discharge criteria Skin integrity plan Speech\language and \or swallowing follow up arranged if needed Consults All consult completed Psychosocial support /education Mobility/Activity Diagnostic laboratory Discharge planning Patent and family are aware of follow up appointment Discharge plan completed Follow up outpatient therapy as appropriate Out patient blood work arranged Patient is safe immobility and activities od daily living Appropriate aids if required Safety education for patient and family Patient awer of risk factors and management Patent and family have understand od stroke eductions Nutrition Patient receives adequate nutrition and appropriate hydration Consulted dietitian


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