HeadInjuryPathway头部外伤临床路径

HeadInjuryPathway头部外伤临床路径AlexandraHospital亚历山大医院(DEM&WARDPathway)急诊及病房路径DRUGALLERGY药物过敏PATIENT'SSTICKYLABEL病人标签WARD/BEDNO病区/床号.:InclusionCriteriaforHeadInjuryClinicalPathway头部外伤临床路径纳入PatientadmittedwithprincipaldiagnosisofminorheadinjurywithGCSscoreof14andabove.病人入院主要诊断为轻度头部外伤，GCS评分14分及以上。Criteriaforadmission:PatientwithGCS14-15HistoryoflossofconsciousnessSkullfracture,onX-rayclinicallyNeurologicalsignsandsymptomsVomitingHeadache入院标准：GCS评分14-15历史的意识丧失颅骨骨折，临床X射线诊断，神经系统症状和体征呕吐头痛ExclusionCriteriaforHeadInjuryClinicalPathway头部外伤临床路径排除标准Patientwithothersystemicinjuries病人有其他系统损伤GCS<14Difficultyinassessingpatientduetointoxication病人因中毒难以评估GuidelinesforUse使用指南WhentostartthePathway?何时开始路径？Canbestartedonanydayduringtheadmissionepisode可在住院的任何一天开始启用HowtousethePathway?2.如何使用路径？ForDoctors针对医生‘Tick&signallrequiredstandardorders(SNwillonlycarryoutordersasticked&signedbydoctors)‘Enteradditionalordersinthespaceprovided,indicatedate&timeofentry‘Writeyourname,MCRNo.andsignonthedailyPathway,aftercompletingtheorder(s).在所有标准规程(医嘱)上打勾并签字，护士仅执行医生打勾并签字后的规程(医嘱)在提供的空白处增加额外的医嘱，注明日期、时间完成医嘱后，写下姓名、MCR号码并在每日路径上签字ForNurses&OtherAlliedHealthcareProfessionals针对护士和其他辅助医疗人员‘Carryoutordersasticked&signedbydoctorConsultDoctor/CaseManagerIn-chargeifthereisanyproblemwiththedocumentationofthePathway.PutaV"intheifaction/interventionisdone'Puta-"'intheifnotapplicable"Putan"x”intheforactions/interventionsnotdone/achievedanddocumentthereason(s).Passovertothenextshifttofollowupwiththecare/interventions执行由医生打勾签字的医嘱咨询医生/个案主管，如果有任何路径文件的问题/干预工作执行完毕后打V”不适用则写“一”没有执行的打“x”，并记录原因。向下一班交班需要做的措施与干预。ForallHealthCareProfessionals针对所有卫生保健人员ForallHealthCareProfessionals针对所有卫生保健人员ReportonthePathwayduringinter-shifthandover/doctorsward'roundDiscussthefollowingwiththeMultidisciplinaryTeam:Planofcareiv)DischargeplansCriticaleventsv)ELOSProgressofthepatientvi)Patient/family'sneeds在交接班和医生查房时报告路径(的情况)与多学科团队讨论：护理重要事件病人的进展岀院计划ELOS病人/家庭需要3.WhattodoifpatientistakenoffthePathway?如果病人要退出路径，怎么做？‘ExitfromthePathwaycompletelyandreverttotheusualdocumentationDocumentthereason(s)forexitingfromthePathwayContinuetomonitorkeyindicatorsasstatedinthePathwayCompletetheVarianeeRecordForm从路径退岀，恢复常规记录记录退岀路径的原因继续监测路径规定的关键指标填写变异记录表Note:ThisPathwayservesasaguideandcommunicationtoolforhealthcareprofessionalstocoordinatepatientcare.Itisnotintendedorconstruedasthestandardofmedicalcare.Itmaybemodifiedtomeetindividualpatient'sneeds.注意此路径可作为医疗专业人员的指导与交流工具，以统筹病人的管理。此路径并非医疗护理的标准。此路径可修改，以适应病人的个性化需求。AffixPatientAffixPatientsStickyLabelHere此处粘贴病人标签ClinicalPathwayforMinorHeadInjury轻度头部损伤临床路径Date日期：Unit单位Ward病区Bed床号Class级别(AdmissionDay入院日期)EmergencyDepartment急诊室StandardOrder标准医嘱(VintheDifdone/order)执行后或开医嘱则在□中打VNursingIntervention护理处置(Vinthe□ifdone,Xifnotdone,-ifnotapplicable)执行后在□中打V,未执行打x,不适用写--CTHeadifanyofthefollowing:GCS<15at2hrsormoreafterinjurySuspectedopenordepressedskullfractureAnysignofbasalskullfractureTwoormoreepisodeofvomitingAge,65yearsorolderMorethan30minsofamnesiapriortoinjurySeveremechanismofinjury:-RTAFallfrommorethan1mFallfrom5ormorestairsLookforassociatedcervicalspineinjury□如果有以下情况，做头部CT:伤后2小时或以上GCS评分<15怀疑开放性或凹陷性颅骨骨折颅底骨折的任何迹象呕吐两次以上年龄65岁以上受伤之前30分钟失忆严重的损伤：道路交通事故跌落1米以上跌落5级以上楼梯□检查是否有颈椎损伤MonitorGCSevery30mins.InformdoctorifGCS<14每30分钟测GCS,GCS<14时医生Applycervicalcollarifsuspectedneckinjury怀疑颈椎损伤时，放置颈托Ifadmitted:如果入院Instructandobservenilbymouth指导并监测禁食Ifdischarged如果出院Giveheadinjuryadvice给与头部损伤宣教SignatureofDoctor:医生签字NameofDoctor:医生名字MCRNo:Shift班次NameandSignatureofStaffNurse护士签名Time:时间AdditionalOrders添加医嘱(IndicateDateandTime)注明日期和时间MultidisciplinaryTeamNotes多学科团队记录AdditionalOrders添加医嘱(IndicateDateandTime注明日期和时间MultidisciplinaryTeamNotes多学科团队记录AffixPatientsStickyLabelHereClinicalPathwayforMinorHeadInjury(DRG052)轻度头部损伤临床路径AffixPatientsStickyLabelHereClinicalPathwayforMinorHeadInjury(DRG052)轻度头部损伤临床路径Date:(AdmissionDay入UnitWardBedClass院日）StandardOrderNursingIntervention(VintheDifdone/order)(Vinthe□ifdone,Xifnotdone,-ifnotapplicable)□PatientclerkedbydoctorwithinIhourDoctorinformedathrs.□□□口医生在1小时内处理病人通知医生时间：□CarefulassessmentforcauseoffallandClerkedbyDrathomecircumstances,particularlyinthe处理医生：时间：elderlyHourlyparametersincludingCLC,inform□□□□仔细检查跌倒原因和家庭环境，特别是老人doctorifGCS<14□FBCandRenalPanel(>65yrsoldif每小时生命体征包括意识，GCS<14时通知医生□□□□indicated)Painassessmentandmanagement血常规、肾功能（65岁以上老人需要时）疼痛评估、处理□□□□□ToiletandsutureifrequiredFallpreventioninterventionsreferto清创、缝合（需要时）Checklist□Nilbymouthtillreview跌倒预防措施-按检查单□□□□禁食直至再次评估后HeadInjuryadvice,referPFErecord□Intravenoustherapy(Ifnecessary)头部损伤宣教，根据宣教记录□□□□静脉输液（需要时）Cervicalcollar(ifevideneeofneckinjury)□Hourlyheadchartx12hours颈托（如果有颈部损伤的迹象）每小时头部记录单x12小时DischargePlanning岀院计划Initiatedischargeplanning启动出院计划InformrelativesofELOS(2days)通知家属SignatureofDoctor:ShiftNameandSignatureofStaffNurseNameofDoctor:MCRNo:Time:AdditionalOrders添加医嘱MultidisciplinaryTeamNotes(IndicateDateandTime)多学科团队记录AffixPatientsStickyLabelHereAdditionalOrders(IndicateDateandTime)MultidisciplinaryTeamNotesClinicalPathwayforHeadInjuryDate:(Day1第1天)UnitWardBedClassStandardOrder(VintheDifdone/order)NursingIntervention(VintheDifdone,Xifnotdone,-ifnotapplicable)Assessfitnessfordischarge评估是否能岀院Yes是□No否Dischargecriteria岀院标准Vitalsignsstablefor24hoursNoCSFleakPatientisabletotoleratedietwithnovomitingPatient/carerabletoprovidesafecareoutsidehospital生命体征稳定24小时无脑脊液漏病人能耐受饮食没有呕吐患者在院外能够获得安全的照顾TCUGeneralSurgeryweeks□普外科复诊周后SendX-raysandCTscanfilmsforreportingX-光片、CT片报告6hourlyparametersincludingCLC每6小时监测生命体征、意识Painassessmentandmanagement疼痛评估和处理Fallpreventioninterventions-refertoChecklist跌倒防护-按照检查单Changewounddressingifnecessary换药必要时Encourageambulation鼓励步行Patienteducation,referPFErecord病人教育，根据宣教单DischargePlanning出院计划Finalisedischargeplan完成岀院计划Dischargeadvicegiven给予出院建议□□□□□□□□□□□□□□□□□□□□□□□□□□□□SignatureofDoctor:ShiftNameandSignatureofStaffNurseNameofDoctor:MCRNo:Time:AdditionalOrders(IndicateDateandTime)MultidisciplinaryTeamNotesAdditionalOrders(IndicateDateandTime)MultidisciplinaryTeamNotesClinicalPathwayforHeadInjury头部损伤临床路径Date:(Dav2第2天)UnitWardBedClassDelayedDischargeStandardOrderNursingIntervention(Vinthe□ifdone/order)(VintheDifdone,Xifnotdone,-ifnotapplicable)□Assessfitnessfordischarge评估能否岀6hourlyparametersincludingCLC□□□□院每6小时监测生命体征、意识□Yes是□No否Painassessmentandmanagement□□□□Dischargecriteria岀院标准疼痛评估和处理1.Vitalsignsstablefor24hoursFallpreventioninterventions-referto□□□□2.NoCSFleakChecklist3.Patientisabletotoleratedietwithno跌倒防护-按照检查单vomitingChangewounddressingifnecessary4.Patient/carerabletoprovidesafecare换药必要时□□□□outsidehospitalEncourageambulation□□□□1.生命体征稳定24小时鼓励步行2.无脑脊液漏Patienteducation,referPFErecord3.病人能耐受饮食没有呕吐病人教育，根据宣教单□□□□4.患者在院外能够获得安全的照顾DischargePlanning□□□□□TCUGeneralSurgeryweeks出院计划□普外科复诊周后Finalisedischargeplan□SendX-raysandCTscanfilmsfor完成岀院计划reporting□X-光片、CT片报告SignatureofDoctor:ShiftNameandSignatureofStaffNurseNameofDoctor:MCRNo:Time:AdditionalOrdersMultidisciplinaryTeamNotes(IndicateDateandTime)AdditionalOrders(IndicateDateandTime)MultidisciplinaryTeamNotesVARIANCERECORDFORM变异记录单UNIT单位CLASS级别WARD病房BED床号DateofAdmission入院日期：Consultant-in-charge:Instructions指导：KeyIndicators:关键指标・Lengthofstay住院日*Readmission再入院□<15days15天内□<30days一个月内*Complicationduringstay住院期间并发症DocumentVariance记录变异Track&recordkeyindicators追踪和记录关键指标Recordco-morbidcondition(s)记录并发疾病情况TrackfactorsthatprolongLOS&affectpatient'soutcome追踪延长病人住院的因素和病人受影响的结果Dischargedto岀院去向：Home家□Rehab.Services康复设施NursingHome护理之家Others其它:Upondischarge,submitthisFormtoCaseManager出院时，将此表交案例经理Date日期Description描述ActionTaken措施Signature签名Co-morbidConditions并发疾病情况：(Tickaccordingly合适处打钩)□Nil无□Hypertension高血压□Anaemia健忘□IHD血透□Arrhythmia:AF/Flutter心律失常□OldAMI陈旧心梗□CCF慢性心衰□OldStroke陈旧中风□COLD/COPD慢性阻塞性肺病□RenalFailure:Chronic/Acute慢性/急性肾衰□DiabetesMellitus糖尿病□Smoker/Ex-Smoker吸烟/既往吸烟□Gastritis胃炎□Others其它：□Hyperlipidaemia高脂血症PrincipalDiagnosis主诊断:MinorHeadInjuryPrincipalProcedure主要的处置:Medicallyfitfordischargeon岀院适用药物：Dischargedon岀院时间：CT,BrainScandoneon做脑部CT时间：SkullX-raydoneon:做头部X线时间lankPage空白页AffixPatientsStickyLabelHerePATIENTANDFAMILYEDUCATION(HeadInjuryManagement)病人和家庭教育(Tobedoneasearlyasthedayofadmission/within48hours)在入院48小时内完成NameofLearner学习者名字：Relationship关系:A.PATIENTANDFAMILYEDUCATIONASSESSMENT病人和家庭教育评估Instruction扌旨导:Tick(_)theappropriatebox,ifapplicable.Youcantickmorethanoneboxundereachcategory在合适处打钩，每一方面可以多处打钩PatientParticipation病人参与□Yes是□No否Reason原因：FamilyParticipation家庭参与□Yes是□No否Reason原因：LanguageofCommunication交流语言□English□Mandarin□Malay□Tamil□Others英语华语马来印度其它LearningNeeds学习需求DiseaseDisorder/ProcessKnowledgeofMedicationCareofDevices(plsspecify):Pain/ComfortMeasureDietModificationOthers(plsspecify):Assessedby评估者:Signature签字Designation&FullNameofStaff姓名Date&Time日期时间B.PATIENTANDFAMILYEDUCATIONRECORD病人和家庭教育记录Instruction:Tick(_)theappropriatebox,ifapplicable.Youcantickmorethanoneboxundereachcategory在合适处打钩，每一方面可以多处打钩LearningObjective(s):Beabletoshowevidenceofunderstandingandknowledgeofthefollowing:学习目标：能够显示对以下内容的理解与知识KnowledgeonHeadInjury头部损伤知识Symptoms症状Theneedforhospitalizationforobservation住院观察的需要Optionsforinterventionintheeventofchangeincondition情况变化时的处理选择HeadInjuryAdvice头部损伤建议ToreturntoEmergencyDepartmentimmediatelyifthefollowingoccurswithinfirst24to48hours如果24至48小时内出现以下症状，立即返回急诊Drowsiness嗜睡Headache,giddiness头痛，头晕Vomiting呕吐Blurringordoublevision视物模糊Weaknessofarmsandlegs手脚软弱Slurringorlossofspeech语言缓慢或不能说话Disorientation,confusionorirritablebehaviour定向障碍，模糊，行为过激Fitsoranykindofseizures扌由搐、震颤KnowledgeonPreventionofFalls预防跌倒的知识Highriskpatientsadvisedon:高危因素Medication(formedicalcondition)药物Correctionofpoorvision视力不佳Modificationofenvironment环境改变Needforcarer需要照顾者Optionsforcommunityresources-DayCareCentre选择公共资源一日间照顾中心KnowledgeonMedication药物知识Dosing,timing剂量，时间Actionandsideeffects作用和副作用Potentialinteractionbetweenmedicationandfood药物和食物之间潜在相互作用Importanceofmedicationadherence按医嘱用药的重要性Importantadviceupondischarge出院建议Nottotakealcohol戒酒Nottodrive/Operatemachinery不要驾驶、不要操作机器InfectionControl感染控制-□AirbornePrecaution空气防护□DropletPrecaution飞沫防护□ContactPrecaution接触防护□Handwashing洗手□Minimizebringingitemsintopatient'sro尽可能少带物品进入病人房间Keepdoorclosed关门□Educateondonning,removalanddiscardofsurgicalmask教育戴口罩、去除口罩和丢弃口罩的Restrictvisitors限制探视□Educateondonning,removalanddiscardofN95mask教育戴N95口罩的方法Unwellvisitorsareadvisednottoenterpatient'sr劝阻生病探视者进入病人房间TeachingMethod（s）教育方法□Demonstration展示□Video视频□Visualaid可视□PatientPathway病人路径□Pamphlet/Booklet/Leaflet宣传册/页□Others（plsspecify）:其它TeachingMaterialgiventolearner给学习者的资料（ifapplicable适用时）：Asthmabooklet哮喘小册子□PictorialPatientPathway病人路径图画Smokingcessationpamphlet戒烟宣传页□Others其它（plsspecifyConsumables/EquipmentRequired消耗品/设备需求（ifapplicable适用时）:Pleasespecify具体:Remarks记录：Educationgivenby:SignatureDesignation&FullNameofStaffDate&TimeEducationgivento:SignatureNameofLearner/CaregiverDate&Time