HeadInjuryPathway头部外伤临床路径

1、Head Injury Pathway 头部外伤临床路径 Alexandra Hospital 亚历山大医院 (DEM & WARD Pathway) 急诊及病房路径 DRUG ALLERGY 药物过敏 PATIENT S STICKY LABEL 病人标签 WARD / BED NO 病区/床号. : Inclusion Criteria for Head Injury Clinical Pathway 头部外伤临床路径纳入标准 Patient admitted with principal diagnosis of minor head injury with GCS score of 1

2、4 and above. 病人入院主要诊断为轻度头部外伤， GCS评分 14分及以上。 Criteria for admission : 1. Patient with GCS 14-15 2. History of loss of consciousness 3. Skull fracture, on X-ray clinically 4. Neurological signs and symptoms 5. Vomiting 6. Headache 入院标准： 1. GCS 评分 14-15 2. 历史的意识丧失 3. 颅骨骨折，临床 X射线诊断， 4. 神经系统症状和体征 5. 呕吐 6

3、. 头痛 Exclusion Criteria for Head Injury Clinical Pathway头部外伤临床路径排除标准 1. Patient with other systemic injuries病人有其他系统损伤 2. GCS 14 3. Difficulty in assessing patient due to intoxication 病人因中毒难以评估 Guidelines for Use使用指南 1. When to start the Pathway? 何时开始路径？ Can be started on any day during the admission

4、 episode可在住院的任何一天开始启用 2. How to use the Pathway? 2.如何使用路径？ For Doctors 针对医生 Tick & sign all required standard orders (SN will only carry out orders as ticked & signed by doctors) Enter additional orders in the space provided, indicate date & time of entry Write your name, MCR No. and sign on the dai

5、ly Pathway, after completing the order(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 For Nurses & Other Allied Healthcare Professionals针对护士和其他辅助医疗人员 Carry out orders as ticked & signed by doctor Consult Doctor / Case Manager In-charge if there is any p

6、roblem with the documentation of the Pathway. Put a “”i n the if action/intervention is done Put a “-”i n the if not applicable Put an “”i n the for actions /interventions not done/achieved and document the reason(s). Pass over to the next shift to follow up with the care/interventions 执行由医生打勾签字的医嘱

7、咨询医生 /个案主管，如果有任何路径文件的问题 措施/干预工作执行完毕后打“” 不适用则写 “ ” 没有执行的打“” ，并记录原因。向下一班交班需要做的措施与干预。 For all Health Care Professionals 针对所有卫生保健人员 Report on the Pathway during inter-shift handover / doctorsward ro und Discuss the following with the Multidisciplinary Team: i) Plan of care iv) Discharge plans ii) Critic

8、al events v) ELOS iii) Progress of the patient vi) Patient/family s needs 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： 1. 护理计划 2. 重要事件 3. 病人的进展 4. 出院计划 5. ELOS 6. 病人/家庭需要 3. What to do if patient is taken off the Pathway? 如果病人要退出路径，怎么做？ Exit from the Pathway completely and revert to the usual documentation Documen

9、t the reason(s) for exiting from the Pathway Continue to monitor key indicators as stated in the Pathway Complete the Variance Record Form 从路径退出，恢复常规记录 记录退出路径的原因 继续监测路径规定的关键指标 填写变异记录表 Note: i) This Pathway serves as a guide and communication tool for healthcare professionals to coordinate patient ca

10、re. ii) It is not intended or construed as the standard of medical care. iii) It may be modified to meet individual patients needs. 注意 1.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。 2. 此路径并非医疗护理的标准。 3. 此路径可修改，以适应病人的个性化需求。 Affix Patient s Sticky Label Here 此处粘贴病人标签 Clinical Pathway for Minor Head Injury 轻度头部损伤临床路径

11、 Date 日期 : Unit 单位 Ward 病区 Bed床号 Class级别 (Admission Day 入院日期 ) Emergency Department 急诊室 Standard Order 标准医嘱 (in the if done/order) 执行后或开医嘱则在 中打 Nursing Intervention 护理处置 ( in the if done, X if not done, - if not applicable) 执行后在 中打 ，未执行打，不适用写 - CT Head if any of the following: GCS 15 at 2 hrs or mor

12、e after injury Suspected open or depressed skull fracture Any sign of basal skull fracture Two or more episode of vomiting Age, 65 years or older More than 30 mins of amnesia prior to injury Severe mechanism of injury: RTA Fall from more than 1m Fall from 5 or more stairs Look for associated cervica

13、l spine injury 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 Monitor GCS every 30 mins. Inform doctor ifGCS 14 每30分钟测 GCS ，GCS 14 时通知医生 Apply cervical collar if suspected neck injury 怀疑颈椎损伤时，放置颈托 If admitted: 如果入院

14、Instruct and observe nil by mouth指导并监测禁食 If discharged 如果出院 Give head injury advice 给与头部损伤宣教 Signature of Doctor: 医生签字 Name of Doctor: 医生名字 MCR No: Shift 班次 Name and Signature of Staff Nurse 护士签名 Time: 时间 Additional Orders 添加医嘱 (Indicate Date and Time)注明日期和时间 Multidisciplinary Team Notes 多学科团队记录 Add

15、itional Orders 添加医嘱 (Indicate Date and Time)注明日期和时间 Multidisciplinary Team Notes 多学科团队记录 Affix Patient s Sticky Label Here Clinical Pathway for Minor Head Injury ( DRG 052 )轻度头部损伤临床路径 Date : (Admission Day 入 Unit Ward Bed Class 院日 ） Standard Order Nursing Intervention (in the if done/order) ( in the

16、 if done, X if not done, - if not applicable) Patient clerked by doctor within 1hour Doctor informed at hrs. 医生在 1 小时内处理病人 通知医生时间： Careful assessment for cause of fall and Clerked by Dr _ at home circumstances, particularly in the 处理医生： 时间： elderly Hourly parameters including CLC, inform 仔细检查跌倒原因和家庭

17、环境， 特别是老人 doctor if GCS 65 yrs old if 每小时生命体征包括意识， GCS 14 时通知医生 indicated) Pain assessment and management 血常规、肾功能（ 65 岁以上老人需要时） 疼痛评估、处理 Toilet and suture if required Fall prevention interventions refer to 清创、缝合（需要时） Checklist Nil by mouth till review 跌倒预防措施 按检查单 禁食直至再次评估后 Head Injury advice, refer P

18、FE record Intravenous therapy (If necessary) 头部损伤宣教，根据宣教记录 静脉输液（需要时） Cervical collar (if evidence of neck injury) Hourly head chart x 12 hours 颈托（如果有颈部损伤的迹象） 每小时头部记录单 x 12 小时 Discharge Planning 出院计划 Initiate discharge planning 启动出院计划 Inform relatives of ELOS (2 days) 通知家属 Signature of Doctor: Shift

19、Name and Signature of Staff Nurse Name of Doctor: MCR No: Time: Additional Orders 添加医嘱 Multidisciplinary Team Notes (Indicate Date and Time) 多学科团队记录 Additional Orders (Indicate Date and Time) Multidisciplinary Team Notes Affix Patient s Sticky Label Here Clinical Pathway for Head Injury Date : (Day

20、1 第 1天 ) Unit Ward Bed Class Standard Order (in theif done/order) Nursing Intervention ( in the if done, X if not done, - if not applicable) Assess fitness for discharge 评估是否能出院 Yes 是 No 否 Discharge criteria 出院标准 1. Vital signs stable for 24 hours 2. No CSF leak 3. Patient is able to tolerate diet w

21、ith no vomiting 4. Patient/carer able to provide safe care outside hospital 1.生命体征稳定 24 小时 2. 无脑脊液漏 3.病人能耐受饮食没有呕吐 4.患者在院外能够获得安全的照顾 TCU General Surgery weeks 普外科复诊 周后 Send X-rays and CT scan films for reporting X-光片、 CT片报告 6 hourly parameters including CLC 每6小时监测生命体征、意识 Pain assessment and management

22、 疼痛评估和处理 Fall prevention interventions refer to Checklist 跌倒防护 - 按照检查单 Change wound dressing if necessary 换药必要时 Encourage ambulation 鼓励步行 Patient education, refer PFE record 病人教育，根据宣教单 Discharge Planning 出院计划 Finalise discharge plan 完成出院计划 Discharge advice given 给予出院建议 Signature of Doctor: Shift Nam

23、e and Signature of Staff Nurse Name of Doctor: MCR No: Time: Additional Orders (Indicate Date and Time) Multidisciplinary Team Notes Additional Orders (Indicate Date and Time) Multidisciplinary Team Notes Affix Patient s Sticky Label Here Clinical Pathway for Head Injury 头部损伤临床路径 Date : (Day2 第 2天 )

24、 Unit Ward Bed Class Delayed Discharge Standard Order Nursing Intervention (in the if done/order) ( in the if done, X if not done, - if not applicable) Assess fitness for discharge 评估能否出 6 hourly parameters including CLC 院 每6小时监测生命体征、意识 Yes 是 No 否 Pain assessment and management Discharge criteria 出院

25、标准 疼痛评估和处理 1. Vital signs stable for 24 hours Fall prevention interventions refer to 2. No CSF leak Checklist 3. Patient is able to tolerate diet with no 跌倒防护 -按照检查单 vomiting Change wound dressing if necessary 4. Patient/carer able to provide safe care 换药必要时 outside hospital Encourage ambulation 1.生

26、命体征稳定 24 小时 鼓励步行 2. 无脑脊液漏 Patient education, refer PFE record 3.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 Discharge Planning TCU General Surgery weeks 出院计划 普外科复诊 周后 Finalise discharge plan Send X-rays and CT scan films for 完成出院计划 reporting X-光片、 CT片报告 Signature of Doctor: Shift Name and Signature of S

27、taff Nurse Name of Doctor: MCR No: Time: Additional Orders Multidisciplinary Team Notes (Indicate Date and Time) Additional Orders (Indicate Date and Time) Multidisciplinary Team Notes Affix Patient s Sticky Label Here UNIT 单位 CLASS 级别 WARD 病房 BED 床号 Date of Admission 入院日期 : Consultant-in-charge : I

28、nstructions 指导 : Document Variance 记录变异 Track & record key indicators 追踪和记录关键指标 Record co-morbid condition(s)记录并发疾病情况 Track factors that prolong LOS & affect patient s outcome 追踪延长病人住院的因素和病人受影响的结果 Upon discharge, submit this Form to Case Manager 出院 时，将此表交案例经理 VARIANCE RECORD FORM 变异记录单 Key Indicator

29、s : 关键指标 Length of stay 住院日 Readmission 再入院 15 days 15 天内 30 days 一个月内 Complication during stay 住院期间并发症 Date 日期 Description 描述 Action Taken 措施 Signature 签名 Co-morbid Conditions 并发疾病情况 : (Tick accordingly 合适处打钩 ) Nil 无 Hypertension 高血压 Anaemia 健忘 IHD 血透 Arrhythmia: AF/ Flutter 心律失常 Old AMI 陈旧心梗 CCF 慢

30、性心衰 Old Stroke 陈旧中风 COLD/COPD 慢性阻塞性肺病 Renal Failure: Chronic / Acute 慢性 / 急性肾衰 Diabetes Mellitus 糖尿病 Smoker / Ex- Smoker 吸烟 / 既往吸烟 Gastritis 胃炎 Others 其它： Hyperlipidaemia 高脂血症 Discharged to 出院去向 : Home 家 Rehab. Services 康复设施 Nursing Home 护理之家 Others 其它 : Principal Diagnosis 主诊断 : Minor Head Injury P

31、rincipal Procedure 主要的处置 : Medically fit for discharge on 出院适用药物 : Discharged on出院时间 : CT, Brain Scan done on 做脑部 CT 时间 : Skull X-ray done on : 做头部 X 线时间 lank Page空白页 Affix Patient s Sticky Label Here PATIENT AND FAMILY EDUCATION (Head Injury Management )病人和家庭教育 (To be done as early as the day of ad

32、mission/within 48 hours)在入院48 小时内完成 Name of Learner 学习者名字 : Relationship 关系 : A. PATIENT AND FAMILY EDUCATION ASSESSMENT病人和家庭教育评估 Instruction指导: Tick ( _) the appropriate box, if applicable. You can tick more than one box under each category 在合适处打钩，每一方面可以多处打钩 Patient Participation 病人参与 Yes 是 No 否 Re

33、ason 原因 : Family Participation 家庭参与 Yes 是 No 否 Reason 原因 : Language of Communication 交流语言 English Mandarin Malay Tamil Others 英语 华语 马来 印度 其它 Learning Needs 学习需求 Disease Disorder / Process Knowledge of Medication Care of Devices (pls specify) : Pain / Comfort Measure Diet Modification Others (pls spe

34、cify) : Assessed by 评估者 : Signature 签字Designation & Full Name of Staff 姓名 Date & Time 日期时间 B. PATIENT AND FAMILY EDUCATION RECORD病人和家庭教育记录 Instruction : Tick ( _) the appropriate box, if applicable. You can tick more than one box under each category 在合适处打钩，每一方面可以多处打钩 Learning Objective(s) : Be able

35、to show evidence of understanding and knowledge of the following : 学习目标：能够显示对以下内容的理解与知识 1. Knowledge on Head Injury 头部损伤知识 Symptoms 症状The need for hospitalization for observation 住院观察的需要 Options for intervention in the event of change in condition情况变化时的处理选择 2. Head Injury Advice 头部损伤建议 To return to

36、Emergency Department immediately if the following occurs within first 24 to 48 hours 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Blurring or double vision 视物模糊 Weakness of arms and legs 手脚软弱Slurring or loss of speech 语言缓慢或不能说话 Disorientation, confusion or irritable be

37、haviour定向障碍，模糊，行为过激 Fits or any kind of seizures 抽搐、震颤 3. Knowledge on Prevention of Falls 预防跌倒的知识 High risk patients advised on : 高危因素 Medication (for medical condition) 药物 Correction of poor vision 视力不佳 Modification of environment 环境改变Need for carer 需要照顾者 Options for community resources Day Care Centre 选择公共资源 日间照顾中心 4. Knowledge on Medication 药物知识 Dosing, timing 剂量，时间 A