fractured neck of femur - the national hip fracture · pdf filex definite diagnosis of a...
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Page 60 of 60 Page 1 of 60
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ICP Reference No: ACI
Pembrokeshire and Derwen NHS Trust
Integrated Care Pathway
FRACTURED NECK OF FEMUR LEFT Please circle RIGHT
The following criteria must be met for this ICP to be appropriate for a patient: Definite diagnosis of a fractured neck of femur Fracture must not be pathological Patients must not have multiple fractures
Patient Addressograph: Date of admission: Consultant: ……………………………. Type of fracture: ………………………... Department: …………………………… Operation: …………………………….…. This ICP was developed by: Sally Gulliver, Trauma Liaison Nurse, Ward 1 and Multi-disciplinary team Version: One – January 07
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FRACTURED NECK OF FEMUR
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This Integrated Care Pathway (ICP) is a multi-disciplinary
document and will serve as the ward based record of care for this particular admission episode.
This ICP is a guide to the provision of care to patients following a fractured neck of femur. However, professionals are encouraged to maintain their own judgement and assess suitability to remain on the pathway, according to changes in the patient’s condition.
BLACK INK MUST BE USED TO COMPLETE THIS DOCUMENT
The ICP takes the place of all medical and nursing notes. Everyone using the Pathway must document their name, signature and initials on the signature page provided (page 7). Any deviations from the outlined Pathway should be documented by the relevant professional as and, where necessary, acted upon accordingly. Where it has been necessary to remove the patient from the ICP documentation should continue in the medical/nursing notes, and see reasons for coming off the pathway be made clear. Variations may or may not result in the discontinuing of the ICP, professional judgement should always be applied. As far as possible, the ICP should stay as a complete document. Where this has not been possible the relevant professional must ensure that the documentation is returned to its complete state as soon as possible. Contact No: Sally Gulliver, Trauma Liaison Nurse extension 3932 Viv Thirkill Recovery Sister extension 3274
Allergy..............................................................
Warning...........................................................
REFERENCES
Davis P and O’Neill C (2002) The potential benefits of intermittent pnueumatic compression in the prevention of deep venous thrombosis. Journal of Orthopaedic Nursing. 6. pp 95-100.
Morris. R. T. (2004) Evidence based compression. Prevention of stasis and deep vein thrombosis. Lippincott Williams and Wilkins, Annals of Surgery. February. Vol 239. No 2.
NICE Guidelines for the secondary prevention of Osteoporotic fragility fractures in post menopausal women. (2005) January. (review 2007).
Onslow L. (2003) An integral care pathway for fractured neck of femur patients. Professional Nurse. January. Vol 18. No 5.
PEP Trial (2000) The PEP study of Aspirin (86). Pulmonary Embolism Prevention. Lancet 355. pp 1295-1302.
Sign. (2002) Network Prophylaxis of venous thromboenbolism sign. Scottish Intercollegiate Guidelines. Section 3.2
Sign. Guideline 56.
Sign. (2002) Prevention and Management of hip fracture in older people. Edinburgh.
United they stand. Co-ordinating care for elderly patients with hip fracture. The Stationary Office. London.
Welsh Assembly Government (2004/2005) Welsh Emergency Care Access. Collaborative Programme. Appendix 8. p 30.
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FRACTURED NECK OF FEMUR
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Affix patient label here
Date &
Time
MULTIDISCIPLINARY NOTES Medical / Nursing / Allied Health Professionals
Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist,
S= Speech & Lang, Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
Signature Designation
Code Contact No.
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FRACTURED NECK OF FEMUR
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Definition of Nursing Interventions
A signature in the ICP against the nursing intervention containing the following: Pain Controlled Appropriate analgesia been given for pain score? The patient has been reassessed to check that the analgesia has been effective? The intervention/outcome has been documented? Assessments Completed The nutritional screening tool, falls screen, pressure sore prediction scale, moving and handling assessments have been completed/reviewed. Observations completed All observations have been undertaken in line with frequency prescribed on ‘Track and Trigger’ chart and the results fall within acceptable limits i.e. Blood pressure – should be within normal limits Pulse – 60-80 beats per minute Respirations – 15-25 breaths per minute SaO2 – should remain above 98% Temperature – normal 37° Document on ‘track and trigger’ chart Intravenous infusion commenced if indicated and accurate fluid balance A fluid balance chart has been commenced pre-operatively and maintained accurately. Pre-op Paperwork The following have been completed fully and checked for availability in notes:- Theatre checklist Anaesthetic questionnaire Consent form Patient placed on appropriate mattress for PSPS score The pressure sore prediction score has been undertaken and the following actions taken:- PSPS = 11 or below use ‘premierglide’ static mattress PSPS = 12-16 use alternating mattress – nimbus The fractured hip patient will nearly always require an ‘air mattress’ Orientated Patient is orientated as to time and place and what has happened to them? Patient has been assessed for disorientation (due to medication, dehydration and/or confusion). Is it known if this is a new development? Adequate fluid intake Patient has received intervention to encourage fluids and/or if nil by mouth, ensure IV fluids prescribed at correct rate for patients and fluid balance chart maintained accurately.
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GLOSSARY Abbreviations: PSPS - pressure sore prediction scale BP - blood pressure TPR - temperature, pulse, respirations DVT - deep vein thrombosis PE - pulmonary embolism DHS - dynamic hip screw HB - haemaglobin U&E - urea and electrolytes TLN - trauma liaison nurse ADL - activities of daily living ACAH - Acute Care at Home OT - occupational therapist W/B - weight bearing PWB - partial weight bearing NWB - non weight bearing MDT - multidisciplinary team V - variance FBC - full blood count LFT - liver function test G+S - group and save COAG - coagulation CXR - chest x-ray MSU - mid specimen of urine CSU - catheter specimen of urine BD - twice daily TTO - take treatment out CMS - colour, movement and sensation IVI - intravenous infusion IV ABS - intravenous antibiotics Sa O2 - oxygen saturation
FRACTURED NECK OF FEMUR
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Affix patient label here
Date &
Time
MULTIDISCIPLINARY NOTES Medical / Nursing / Allied Health Professionals
Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist,
S= Speech & Lang, Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
Signature Designation
Code Contact No.
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FRACTURED NECK OF FEMUR
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Affix patient label here
Date &
Time
MULTIDISCIPLINARY NOTES Medical / Nursing / Allied Health Professionals
Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist,
S= Speech & Lang, Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
Signature Designation
Code Contact No.
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FRACTURED NECK OF FEMUR
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COLOUR CODES Medical - Red pages Nursing - Blue & white pages Multidisciplinary team - White pages NOTE These are the sections for which you are responsible. Please ensure they are filled in. Medical - inc: clerking notes RED Nursing - inc: all admission documentation and assessments Blue & white MDT - inc: ACAH Doctor white Physio nurse OT Dietitian Pharmacy Specialist Nurse Social worker
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FRACTURED NECK OF FEMUR
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Attach A&E sheets here with Cellotape
A&E casualty card
A&E care plan
FRACTURED NECK OF FEMUR
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Date Code Ongoing care, comments, interventions – all variances must be included with relevant code
Signature and Profession
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FRACTURED NECK OF FEMUR
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Affix patient label here
POST-OP DAY ….. DISCHARGE DAY DATE …………………… MULTIDISCIPLINARY NOTES
Medical / Nursing / Allied Health Professionals Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist, S= Speech & Lang,
Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse INTERVENTIONS AM PM NIGHT COMMENTS
NURSING D1 Pain controlled D2 Orientated D3 Observations recorded D4 Personal hygiene self care D5 Wound dry D6 Discharge checklist + necessary documentation
D7 Medication as prescribed – continue Asprin for 35 days from start date
D8 Adequate diet and fluids taken D9 Pressure areas intact: heels, sacrum D10 Bowels opened PHYSIOTHERAPY D11 Consent to treatment Exercise programme and transfer practice continued
Progress ambulation Gait re-education Walking aid issued OCCUPATIONAL THERAPY D12 Transfer assessments completed Equipment required provided ADL assessments completed MULTIDISCIPLINARY D13 Transport booked D14 Relatives aware D15 Discharge information given D16 Transfer documentation completed
D17 Referral to other services D18 TTO’s explained and given D19 Own medication returned D20 Falls assessment completed D21 Referred to Falls Prevention Officer (if applicable)
D22 Osteoporosis treatment commenced
INITIALS AM PM NIGHT PT OT Ph SRD
FRACTURED NECK OF FEMUR
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SIGNATURE SHEET All staff using this pathway are required to sign below so that signatures and initials used within the pathway can be identified.
PRINT NAME DESIGNATION SIGNATURE INITIALS
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FRACTURED NECK OF FEMUR
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Affix patient label here
PRESENTING HISTORY Presenting problem - pain in hip
- inability to weight bear
- deformity History of present - fall? - how Problem - why - when How long before - relative seen by:
- neighbour/friend
- GP - ambulance personnel Concurrent presenting - hypothermia Problem - dehydration - other
FRACTURED NECK OF FEMUR
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Date Code Ongoing care, comments, interventions – all variances must be included with relevant code
Signature and Profession
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FRACTURED NECK OF FEMUR
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Affix patient label here
POST-OP DAY 10 DATE ……………………………………… MULTIDISCIPLINARY NOTES
Medical / Nursing / Allied Health Professionals
Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist, S= Speech & Lang, Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
INTERVENTIONS AM sign
PM NIGHT sign sign INTERVENTIONS / x
NURSING PHYSIOTHERAPY 10P1 Pain controlled
Consent to treatment
10P2 Orientated
Exercise programme continued
10P3 Temperature apyrexial
Transfer practice continued
10P4 BP recorded
Gait re education
10P5 Wound dry Rehabilitation potential discussed
10P6 Continent OCCUPATIONAL THERAPY
10P7 Adequate fluids taken
Transfer assessment
10P8 Adequate diet taken
Personal ADL assessment
10P9 Fluid balanced
Heights form collected
10P10 Medication as prescribed
PHARMACY
10P11 Pressure areas (sacrum) Intact, colour
Prescription checked
10P12 Pressure areas (heels) intact, colour
Drug therapy monitored
10P13 Personal hygiene with assistance
LIAISON NURSE
10P14 Bowels opened
10P15 Review discharge plan
10P16 Discontinue venaflow pump when mobile
INITIALS AM PM NIGHT PT OT Ph SRD
FRACTURED NECK OF FEMUR
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Affix patient label here
TO BE COMPLETED BY ADMITTING SHO IN A&E MEDICAL HISTORY
PAST MEDICAL HISTORY DETAILS DATE Ischaemic Heart Disease
High Blood Pressure
Atrial Fibrillation
Previous Stroke
Diabetes Mellitus
Hepatitis
Peptic ulcer
Tuberculosis
Asthma
DVT-PE
Epilepsy
MEDICATION Is this likely to predispose to falls?
OPERATIONS (State year)
FAMILY HISTORY
Ischaemic Heart Disease
High Blood Pressure
Stroke
Diabetes Mellitus
Tuberculosis
Asthma
Other
RISK FACTORS Occupation Smoking Alcohol Cholesterol
Estimated length of stay:
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FRACTURED NECK OF FEMUR
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SYSTEM REVIEW CARDIO RESPIRATORY SYSTEM GASTRO-INTESTINAL GENITO-URINARY CENTRAL NERVOUS SYSTEM OTHER
PHYSICAL EXAMINATION Anaemia Cyanosis Clubbing Jaundice Lymphadenopathy Hydration Temperature Skin Thyroid Breasts Other
FRACTURED NECK OF FEMUR
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Date Code Ongoing care, comments, interventions – all variances must be included with relevant code
Signature and Profession
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FRACTURED NECK OF FEMUR
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Affix patient label here
POST-OP DAY 9 DATE ……………………………………… MULTIDISCIPLINARY NOTES
Medical / Nursing / Allied Health Professionals
Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist, S= Speech & Lang, Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
INTERVENTIONS AM sign
PM NIGHT sign sign INTERVENTIONS / x
NURSING PHYSIOTHERAPY 9P1 Pain controlled
Consent to treatment
9P2 Orientated
Exercise programme continued
9P3 Temperature apyrexial
Transfer practice continued
9P4 BP recorded
Gait re education
9P5 Wound dry Rehabilitation potential discussed
9P6 Continent OCCUPATIONAL THERAPY
9P7 Adequate fluids taken
Transfer assessment
9P8 Adequate diet taken
Personal ADL assessment
9P9 Fluid balanced
Heights form collected
9P10 Medication as prescribed
PHARMACY
9P11 Pressure areas (sacrum) Intact, colour
Prescription checked
9P12 Pressure areas (heels) intact, colour
Drug therapy monitored
9P13 Personal hygiene with assistance
LIAISON NURSE
9P14 Bowels opened
9P15 Review discharge plan
9P16 Discontinue venaflow pump when mobile
INITIALS AM PM NIGHT PT OT Ph SRD
FRACTURED NECK OF FEMUR
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Affix patient label here
SYSTEM REVIEW CARDIO VASCULAR SYSTEM Pulse rate Rhythm Character BP Heart Sounds Bruits RESPIRATORY SYSTEM Abdomen
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FRACTURED NECK OF FEMUR
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PHYSICAL EXAMINATION MUSCULOSKELETAL/ORTHOPAEDIC
PHYSICAL EXAMINATION MENTAL TEST SCORE GLASGOW COMA SCORE Age Eye Opening Spontaneous 4 DoB To command 3 Year To pain 2 Time of Day None 1 Place Verbal Response Orientated 5 Monarch Confused 4 WW1 Random 3 20-1 Grunts 2 2 people recognition None 1 Recall address Motor Response Obeys 6 Localises pain 5 Total ……… 10 Withdraws 4 Flexes to pain 3 Extends to pain 2 None 1 Total ……….. 15
FRACTURED NECK OF FEMUR
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Date Code Ongoing care, comments, interventions – all variances must be included with relevant code
Signature and Profession
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FRACTURED NECK OF FEMUR
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Affix patient label here
POST-OP DAY 8 DATE ……………………………………… MULTIDISCIPLINARY NOTES
Medical / Nursing / Allied Health Professionals
Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist, S= Speech & Lang, Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
INTERVENTIONS AM sign
PM NIGHTsign sign INTERVENTIONS / x
NURSING PHYSIOTHERAPY 8P1 Pain controlled
Consent to treatment
8P2 Orientated
Exercise programme continued
8P3 Temperature apyrexial
Transfer practice continued
8P4 BP recorded
Gait re education
8P5 Wound dry Rehabilitation potential discussed
8P6 Continent OCCUPATIONAL THERAPY
8P7 Adequate fluids taken
Transfer assessment
8P8 Adequate diet taken
Personal ADL assessment
8P9 Fluid balanced
Heights form collected
8P10 Medication as prescribed
PHARMACY
8P11 Pressure areas (sacrum) Intact, colour
Prescription checked
8P12 Pressure areas (heels) intact, colour
Drug therapy monitored
8P13 Personal hygiene with assistance
LIAISON NURSE
8P14 Bowels opened
8P15 Review discharge plan
8P16 Discontinue venaflow pump when mobile
INITIALS AM PM NIGHT PT OT Ph SRD
FRACTURED NECK OF FEMUR
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OBSERVATIONS
Result Initials Time Result Initials Time Temperature Weight Blood Pressure Blood Sugar Pulse Glasgow Coma Score Respirations O2 Sats
INITIAL INVESTIGATIONS
Routine May be required Result Result Thyroid LFT FBC CXR U&E COAG G&S X-Match MRSA screen Urinalysis Blood glucose ECG Blood for culture Echo Other
DIFFERENTIAL DIAGNOSIS
Intracapsular fractured femur Intertrochanteric fractured femur Subtrochanteric fractured femur
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FRACTURED NECK OF FEMUR
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* Do not fast the patient until you have a definite
theatre time!
* Decide on operation
prior to booking theatre
Operation type:
…………………………………
* Do not book
theatre until patient is fit for theatre
Name of person
theatre booked with:
………………………………………..
MANAGEMENT PLAN IV Access Remember to prescribe drugs Assess for fluids Sub-cut Patient fit for surgery Yes No Date & Time of planned surgery ………………….. Surgery cancelled Yes No Reason ……………………………………………. Surgery cancelled Yes No Reason ……………………………………………. Surgery cancelled Yes No Reason ……………………………………………. Surgery postponed Yes No Reason ……………………………………………. Surgery postponed Yes No Reason ……………………………………………. Surgery postponed Yes No Reason ……………………………………………. SHO Signature ………………………………. Print Name …………………………………. Date …………………………………………… Time ………………………………………….
FRACTURED NECK OF FEMUR
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Date Code Ongoing care, comments, interventions – all variances must be included with relevant code
Signature and Profession
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FRACTURED NECK OF FEMUR
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Affix patient label here
POST-OP DAY 7 DATE ……………………………………… MULTIDISCIPLINARY NOTES
Medical / Nursing / Allied Health Professionals
Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist, S= Speech & Lang, Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
INTERVENTIONS AM sign
PM NIGHTsign sign INTERVENTIONS / x
NURSING PHYSIOTHERAPY 7P1 Pain controlled
Consent to treatment
7P2 Orientated
Exercise programme continued
7P3 Temperature apyrexial
Transfer practice continued
7P4 BP recorded
Gait re education
7P5 Wound dry Rehabilitation potential discussed
7P6 Continent OCCUPATIONAL THERAPY
7P7 Adequate fluids taken
Transfer assessment
7P8 Adequate diet taken
Personal ADL assessment
7P9 Fluid balanced
Heights form collected
7P10 Medication as prescribed
PHARMACY
7P11 Pressure areas (sacrum) intact, colour
Prescription checked
7P12 Pressure areas (heels) intact, colour
Drug therapy monitored
7P13 Personal hygiene with assistance
LIAISON NURSE
7P14 Bowels opened
7P15 Review discharge plan
7P16 Discontinue venaflow pump when mobile
INITIALS AM PM NIGHT PT OT Ph SRD
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Page 16 of 60 Page 45 of 60
UAP / CORE INFORMATION / SHEET 1
WM
L551
0
01/0
6U
AP
/ C
OR
E I
NF
OR
MA
TIO
N /
SH
EE
T 1
Co
nsul
tant
/GP
:
Are
a S
pec
ific
Info
rmat
ion
(e.g
. vita
l sig
ns, r
elev
ant r
esul
ts, d
irect
ions
, par
ents
’
addr
ess
(Pae
ds),
cod
es e
tc).
Eac
h en
try
mus
t be
date
d an
d si
gned
by
the
nurs
e.
Com
mun
icab
le In
fect
ion
•P
ast M
RS
A in
fect
ion
Yes
No
•C
urre
nt M
RS
A in
fect
ion
Yes
No
•O
ther
rele
vant
com
mun
icab
le in
fect
ion
Yes
No
Pat
ient
Det
ails
Nex
t of K
in
Nam
e:...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.
Rel
atio
nshi
p:...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
..
Add
ress
:....
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
..
Tel.
[H]
......
......
......
......
......
......
......
......
......
[W
]....
......
......
......
......
......
......
......
......
....
IS IN
FOR
MA
TIO
N R
EG
AR
DIN
G Y
OU
R C
LIN
ICA
L C
ON
DIT
ION
TO
BE
GIV
EN
TO
THIS
PE
RS
ON
. (N
amed
Rel
ativ
e)Ye
sN
o
IF Y
OU
AN
SWER
ED N
O T
O T
HE
AB
OVE
QU
ESTI
ON
:-
Nam
e o
f per
son
to d
iscu
ss y
our
clin
ical
co
nditi
on
with
:
Nam
e:...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.
Rel
atio
nshi
p:...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
..
Add
ress
:....
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
..
Tel.
[H]
......
......
......
......
......
......
......
......
......
. [W
]...
......
......
......
......
......
......
......
......
...
Mai
n C
arer
if d
iffer
ent f
rom
Nex
t of K
in
Nam
e:...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.
Rel
atio
nshi
p:...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
..
Add
ress
:....
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
..
Tel.
[H]
......
......
......
......
......
......
......
......
......
. [W
]...
......
......
......
......
......
......
......
......
...
AN
Y IN
FOR
MA
TIO
N G
IVE
N W
ILL
BE
HE
LD IN
CO
NFI
DE
NC
E B
UT
SO
ME
TIM
ES
IT
MA
Y N
EE
D T
O B
E S
HA
RE
D W
ITH
OTH
ER
PR
OFE
SS
ION
ALS
SO
TH
AT
ALL
OF
YOU
R N
EE
DS
CA
N B
E M
ET.
Pat
ient
Sig
n: .
......
......
......
......
......
. N
urse
Sig
n: .
......
......
......
......
... D
ate:
....
......
......
.
THIS
INFO
RM
ATI
ON
CO
MP
LIE
S W
ITH
TH
E R
EQ
UIR
EM
EN
TSO
F TH
E C
ALD
ICO
TT R
EP
OR
T
All
Co
re In
form
atio
n m
ust b
e re
-che
cked
on
ever
y ad
mis
sio
n.
Info
rmat
ion
on re
-adm
issi
on p
rovi
ded
by:
......
......
......
......
......
......
......
......
......
......
......
...
Info
rmat
ion
on r
e-ad
mis
sion
pro
vide
d by
:....
......
......
......
......
......
......
......
......
......
......
....
FRACTURED NECK OF FEMUR
Page 34 of 45
Date Code Ongoing care, comments, interventions – all variances must be included with relevant code
Signature and Profession
Page 44 of 60 Page 17 of 60
FRACTURED NECK OF FEMUR
Page 33 of 45
SAFF TARGET FOR LENGTH OF STAY EXCEEDED STATE REASON WHY?……….…………………………… …………………………………………….……………………………………………………………………………………….
POST-OP DAY 6 DATE ……………………………………… MULTIDISCIPLINARY NOTES
Medical / Nursing / Allied Health Professionals
Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist, S= Speech & Lang, Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
INTERVENTIONS AM sign
PM NIGHTsign sign INTERVENTIONS / x
NURSING PHYSIOTHERAPY 6P1 Pain controlled
Consent to treatment
6P2 Orientated
Exercise programme continued
6P3 Temperature apyrexial
Transfer practice continued
6P4 BP recorded
Gait re education
6P5 Wound dry Rehabilitation potential discussed
6P6 Continent OCCUPATIONAL THERAPY
6P7 Adequate fluids taken
Transfer assessment
6P8 Adequate diet taken
Personal ADL assessment
6P9 Fluid balanced
Heights form collected
6P10 Medication as prescribed
PHARMACY
6P11 Pressure areas (sacrum) Intact, colour
Prescription checked
6P12 Pressure areas (heels) Intact, colour
Drug therapy monitored
6P13 Personal hygiene with assistance
LIAISON NURSE
6P14 Bowels opened
6P15 Review discharge plan
6P16 Discontinue venaflow pump when mobile
INITIALS AM PM NIGHT PT OT Ph SRD
Affix patient label here
ACUTE CORE INFORMATION / SHEET 1B
WM
L 55
25 R
ev. 0
1/06
AC
UT
E C
OR
E I
NF
OR
MA
TIO
N /
SH
EE
T 1
B
Co
nsul
tant
/GP
:
RE
AS
SE
SS
ME
NT
OF
PS
PS
Dat
e/P
SP
S S
core
Equ
ipm
ent r
equi
red
-N
urse
Tim
epl
ease
doc
umen
tS
igna
ture
PS
PS
Scr
eeni
ng m
ust
be
cond
ucte
d w
ithin
6 h
our
s o
f ad
mis
sio
n (N
ICE
2005
)an
d r
e-as
sess
men
t co
nduc
ted
on
a d
aily
bas
is o
r as
th
e p
atie
nt’s
co
nditi
on
chan
ges
.
PR
ES
SU
RE
SO
RE
PR
ED
ICTI
ON
SC
OR
E
PS
PS
= 1
1 o
r b
elo
w
US
E S
TATI
C M
ATT
RE
SS
(P
RE
MIE
RG
LID
E)
PS
PS
= 1
2-16
(ve
ry h
igh
ris
k o
f p
ress
ure
sore
s)
US
E A
LTE
RN
ATI
NG
MA
TTR
ES
S
This
alg
orith
m is
to b
e us
ed a
s a
tool
but
doe
s no
t rep
lace
clin
ical
judg
emen
t.
Dat
e an
d tim
e of
ass
essm
ent:
......
......
......
......
......
......
......
......
......
......
......
......
......
......
...
Req
uire
d in
form
atio
n fo
rwar
ded
to E
ME
(W
GH
onl
y)...
......
......
......
......
......
......
......
......
i.e.:
D N
umbe
r, Lo
catio
n, C
linic
al J
ustif
icat
ion
(if P
SP
S 1
1 or
less
)
Equ
ipm
ent r
ecei
ved
on...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
....
Equ
ipm
ent a
cqui
red
from
: Hos
pita
l sto
ckLe
ase
Ren
tal
Nur
se s
igna
ture
:....
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
..
Pat
ient
Det
ails
No
No,
but
Yes,
but
Yes
Sitt
ing
up?
(long
tim
e)0
12
3
Unc
onsc
ious
?0
12
3
Poo
r gen
eral
con
ditio
n?0
12
3
Inco
ntin
ent?
01
23
No
Yes
& N
oYe
sS
core
Lifts
up?
21
0
Get
s up
and
wal
ks?
21
0
If pr
essu
re s
ores
pre
sent
+10
, com
plet
e W
ound
Ass
essm
ent f
orm
and
util
ise
appr
opria
te a
ids
e.g.
cus
hion
s
SU
PP
OR
T S
UR
FAC
E A
LGO
RIT
HM
S
Page 18 of 60 Page 43 of 60
SIT
TIN
G U
P?
(Lon
g tim
e)A
nsw
er+
Sco
rea]
Bed
fast
and
nur
sed
flat
b]O
nly
sit u
p in
a c
hair
-sh
ort p
erio
dsc]
Doe
s no
t sit
for l
ong
perio
ds (a
mbu
lant
)
a]S
its in
sel
f pro
pelle
dch
air (
less
than
10h
rs)
but f
lat w
hen
in b
ed
a]S
its in
sel
f pro
pelle
dch
air f
or 1
0 hr
s or
mor
e.b]
Sits
for s
hort
per
iods
-bo
th in
bed
and
in fi
xed
chai
r
a]P
ropp
ed u
p in
bed
-lo
ngis
h pe
riods
- m
ost
of th
e da
yb]
Sits
up
both
day
and
nig
ht
UN
CO
NS
CIO
US
a]Fu
lly c
onsc
ious
and
orie
ntat
edb]
Fully
con
scio
us a
ndsl
ight
ly c
onfu
sed
a]C
onfu
sed
b]W
ithdr
awn
c]S
emi-c
onsc
ious
at t
imes
a]R
ousa
ble
- res
pond
sto
com
man
ds o
f pai
n
a]D
eepl
y un
cons
ciou
sb]
Doe
s no
t res
pond
to p
ain
PO
OR
GE
NE
RA
L C
ON
DIT
ION
Ans
wer
+ S
core
a]Fa
irly
good
gen
eral
con
ditio
nb]
Aw
aitin
g m
inor
ope
ratio
nc]
Min
or p
robl
em (m
enta
lor
phy
sica
l)
a]R
ecen
t ope
ratio
n (u
nder
G.A
.)b]
Som
e re
stric
tion
of lo
wer
extr
emiti
esc]
Min
or s
enso
ry n
euro
path
yd]
Per
ip. a
rter
ial d
isea
see]
diab
etic
f]A
rthr
itic
g]A
nore
xic
h]P
yrex
ial
i]H
ypot
ensi
vej]
On
ster
oids
k]C
hem
othe
rapy
l]R
adio
ther
apy
m]
Eld
erly
and
thin
, or o
bese
a]S
ome
inju
ries
to lo
wer
hal
f of
body
, but
fair
gene
ral c
ondi
tion
b]S
ever
e in
jurie
s (lo
wer
hal
f) b
utno
rest
rictio
n of
mov
emen
tc]
Wel
l est
ablis
hed
chro
nic
dise
ase/
disa
bilit
yd]
Youn
g pa
rapl
egic
e]A
ctiv
e he
mip
legi
cf]
Eld
erly
and
on
ster
oids
a]Li
mite
d m
obili
ty a
nd g
reat
age
b]S
ever
e in
jurie
s - i
nclu
ding
legs
/pel
vis
c]S
erio
usly
/crit
ical
ly il
ld]
Term
inal
(acu
te) i
llnes
se]
Em
acia
ted/
Cac
hexi
cf]
Sev
ere
gene
ral i
nfec
tion
g]S
ever
e ur
aem
iah]
Mul
tiple
pat
holo
gyi]
Iliac
. thr
ombo
sis
j]S
ever
e M
.S.
k]H
anse
n’s
dise
ase
l]E
xten
sive
loss
of p
ain
m]
Rec
ent p
arap
legi
cn]
Qua
drap
legi
co]
On
narc
otic
s (f
or p
ain)
p]C
ombi
ned
chem
othe
rapy
,ra
diot
hera
py a
nd /o
r ste
roid
s
INC
ON
TIN
EN
T?A
nsw
er+
Sco
re
a]N
o in
cont
inen
ce, a
nd n
o“a
ccid
ents
” re
cent
lyb]
Indw
ellin
g ca
th/s
tom
a,bu
t no
leak
s/ac
cide
nts
a]S
omet
imes
wet
s be
d/sp
ills
urin
alb]
Occ
asio
nal a
ccid
ents
with
atta
ched
urin
alc]
Occ
asio
nal l
eaks
from
indw
ellin
g ca
thet
erd]
Occ
asio
nal f
aeca
lin
cont
inen
ce
a]S
mal
l am
ount
s an
din
frequ
ent
b]U
rine
only
and
infre
quen
tc]
Faec
al (i
nfre
quen
t) b
utso
me
leak
s (c
ath/
urin
el)
a]C
ontin
ual d
ribbl
e/le
akb]
Freq
uent
urin
e/fa
ecal
inco
ntin
ence
c]D
oubl
y in
cont
inen
t
LIF
TS U
P?
a]Li
fts a
ll of
bod
y cl
ear
of s
uppo
rtb]
Eas
ily li
fts p
elvi
s cl
ear
a]C
an o
nly
lift p
elvi
s w
ithso
me
effo
rt a
nd s
oon
tires
b]S
eldo
m li
fts s
elf
c]C
an li
ft w
ith h
elp
d]Li
fts s
light
ly -
shuf
fles
alon
g su
ppor
t
a]U
nabl
e to
lift
pelv
isb]
Can
nei
ther
hel
p w
ithlif
t, no
r shu
ffle
GE
TS U
P A
ND
WA
LKS
?A
nsw
er+
Sco
re
a]Fu
lly a
mbu
lant
b]S
light
impe
dim
ent
c]U
ses
side
with
no
diffi
culty
a]H
as d
iffic
ulty
wal
king
with
aid
b]W
alks
with
hel
p an
den
cour
agem
ent
c]S
oon
tires
d]C
an o
nly
wal
k to
toile
t
a]B
edfa
stb]
Cha
irfas
tc]
Sta
nds
and
shuf
fles
-w
ith h
elp
and
enco
urag
emen
t
NO 0 NO
,B
ut ..
1
YES
,B
ut ..
2
YES 3 N
O 0 NO
,B
ut..
1
YES
,B
ut..
2
YES 3
NO 0 NO
,B
ut..
1
YES
,B
ut..
2
YES 3
NO 0 NO
,B
ut..
1
YES
,B
ut..
2
YES 3
YES 0
YES
& NO 1 NO 2
YES 0
YES
& NO 1 NO 2
This
pre
ssur
e so
re p
reve
ntio
n ai
d w
asd
eve
lop
ed
at
the
Ro
yal
Nat
ion
alO
rtho
pae
dic
Ho
spita
l (N
HS
) Tr
ust,
Sta
nmor
e, M
iddl
esex
.
ACUTE CORE INFORMATION / SHEET 1B
WM
L 55
25 R
ev. 0
1/06
AC
UT
E C
OR
E I
NF
OR
MA
TIO
N /
SH
EE
T 1
B
FRACTURED NECK OF FEMUR
Page 32 of 45
Date Code Ongoing care, comments, interventions – all variances must be included with relevant code
Signature and Profession
Page 42 of 60 Page 19 of 60
FRACTURED NECK OF FEMUR
Page 31 of 45
Affix patient label here
POST-OP DAY 5 DATE ……………………………………… MULTIDISCIPLINARY NOTES
Medical / Nursing / Allied Health Professionals
Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist, S= Speech & Lang, Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
INTERVENTIONS AM sign
PM NIGHT sign sign INTERVENTIONS / x
NURSING PHYSIOTHERAPY 5P1 Pain controlled
Consent to treatment
5P2 Orientated
Exercise programme continued
5P3 Temperature apyrexial
Transfer practice continued
5P4 BP recorded
Gait re education
5P5 Wound dry Rehabilitation potential discussed
5P6 Continent OCCUPATIONAL THERAPY
5P7 Adequate fluids taken
Transfer assessment
5P8 Adequate diet taken
Personal ADL assessment
5P9 Fluid balanced
Heights form collected
5P10 Medication as prescribed
PHARMACY
5P11 Pressure areas (sacrum) Intact, colour
Prescription checked
5P12 Pressure areas (heels) Intact, colour
Drug therapy monitored
5P13 Personal hygiene with assistance
LIAISON NURSE
5P14 Bowels opened
5P15 Review discharge plan
5P16 Discontinue venaflow pump when mobile
INITIALS AM PM NIGHT PT OT Ph SRD
UAP / NURSING ASSESSMENT / SHEET 2
WM
L553
0 -
01/0
6U
AP
/ N
UR
SIN
G A
SS
ES
SM
EN
T /
SH
EE
T 2
Co
nsul
tant
/GP
NE
ED
S ID
EN
TIFI
ED
Pre
-Adm
issi
on /
Cur
rent
Sta
tus
Nur
se S
ign
......
......
......
......
......
......
......
......
......
......
......
......
.
Nur
se D
ate
......
......
......
......
......
......
......
......
......
......
......
......
.
Pat
ient
Det
ails
Hos
p. N
o:N
HS
No:
Sur
nam
e:E
. No:
Fore
nam
es:
Pre
sent
Add
ress
:P
ost C
ode:
Like
s to
be
know
n as
:
Tel.
No:
......
......
......
......
......
......
......
......
.D
OB
:A
ge:
1.Us
er’s
Per
spec
tive
·Pr
oble
ms
and
issu
es in
the
user
’s o
wn
wor
ds
·Us
er’s
exp
ecta
tions
, ne
eds,
stre
ngth
s, a
bilit
ies
and
mot
ivat
ion
incl
udin
g cu
ltura
l and
soc
ial
expe
ctat
ions
·Re
cent
life
eve
nts
— in
clud
ing
stre
ngth
s an
d co
ping
mec
hani
sms
·Pe
rson
al a
nd s
pirit
ual f
ulfil
men
t and
life
-sty
le c
hoic
es
·Is
sues
sur
roun
ding
the
patie
nt’s
leve
l of a
nxie
ty, f
ears
, sel
f est
eem
and
bod
y im
age.
·He
alth
per
cept
ion,
spi
ritua
l bel
iefs
, men
tal h
ealth
. Adv
ocac
y ne
eds.
2.Ca
rer’
s pe
rspe
ctiv
e an
d ne
ed fo
r car
er a
sses
smen
t
·Ph
ysic
al d
iffic
ultie
s in
car
ing
·Ps
ycho
logi
cal d
iffic
ultie
s an
d pr
essu
res
aris
ing
from
car
ing
role
, inc
ludi
ng s
hock
, grie
f, in
adeq
uacy
·Li
fe c
onst
rain
ts a
risin
g fro
m c
arin
g ro
le, e
.g. c
lash
es w
ith e
mpl
oym
ent,
child
car
e re
spon
sibi
litie
s,
leis
ure
activ
ity
·Ca
rer’s
stre
ngth
s, e
xpec
tatio
ns, m
otiv
atio
n an
d pe
rcep
tion
of h
er/h
is n
eeds
and
use
r’s n
eeds
·Is
sues
aro
und
supp
ort/r
elat
ions
hips
with
fam
ily, c
arer
s, fr
iend
s
·Is
sues
aro
und
the
patie
nt’s
abi
lity
to c
ope
at h
ome.
Cur
rent
car
e re
ceiv
ed
3.Cl
inic
al b
ackg
roun
d
·Is
sues
aro
und
the
patie
nt’s
env
ironm
ent a
nd h
ow h
e/sh
e is
abl
e to
cop
e
·Is
sues
aro
und
mob
ility/
aids
use
d, p
hysi
cal a
ctiv
ity, p
atte
rns
of e
xerc
ise,
his
tory
of f
alls
(com
plet
e
Stra
tify)
·Br
eath
ing
diffi
culti
es, h
isto
ry o
f obs
truct
ive
airw
ay d
isea
se.
·Is
sues
aro
und
the
patie
nt’s
resp
irato
ry fu
nctio
n, c
onsi
der r
efer
ral t
o Re
spira
tory
CNS
4.Di
seas
e pr
even
tion
·Hi
stor
y of
blo
od p
ress
ure
mon
itorin
g
·Is
sues
aro
und
the
patie
nt’s
nut
ritio
nal i
ntak
e, p
refe
renc
es a
nd h
ydra
tion,
alc
ohol
inta
ke.
·Va
ccin
atio
n hi
stor
y - i
nclu
ding
Flu
vac
ine
·Do
es th
e pa
tient
sm
oke,
how
man
y?
·Is
sues
aro
und
mob
ility,
phy
sica
l act
ivity
, pat
tern
s of
exe
rcis
e, c
onsi
der r
efer
ral t
o Ph
ysio
·Hi
stor
y of
scr
eeni
ng c
linic
s at
tend
ed
Page 20 of 60 Page 41 of 60
UAP / NURSING ASSESSMENT / SHEET 2
WM
L553
0 -
01/0
6U
AP
/ N
UR
SIN
G A
SS
ES
SM
EN
T /
SH
EE
T 2
NE
ED
S ID
EN
TIFI
ED
Pre
-Adm
issi
on /
Cur
rent
Sta
tus
5.Pe
rson
al c
are
and
phys
ical
wel
l-bei
ng·
Pain
- co
mpl
ete
pain
scr
eeni
ng/c
onsi
der r
efer
ral t
o CN
S ac
ute
or c
hron
ic p
ain,
if w
ound
/pre
ssur
eso
re p
rese
nt c
ompl
ete
wou
nd a
sses
smen
t, re
cord
PSP
S.·
Foot
-car
e, c
onsi
der r
efer
ral t
o Po
diat
ry·
Issu
es a
roun
d ca
rdio
vasc
ular
and
per
iphe
ral s
yste
m, s
yste
mic
per
fusi
on, s
kin
inte
grity
- co
nsid
erre
ferra
l to
TV N
urse
Pra
ctiti
oner
·Is
sues
aro
und
mob
ility,
phy
sica
l act
ivity
, pat
tern
s of
exe
rcis
e, a
bilit
y to
clim
b st
airs
·Is
sues
roun
d ex
cret
ory
func
tion
and
abno
rmal
ities
. (Bo
wel
, urin
e ou
tput
, men
stru
atio
n). C
onsi
der
refe
rral t
o Co
ntin
ence
CNS
/Sto
ma
CNS
·Co
nsid
er p
atie
nt’s
pat
tern
of s
leep
, res
t, re
laxa
tion
and
perc
eptio
n of
ene
rgy
leve
ls
6.Ac
tiviti
es o
f Dai
ly li
ving
·Is
sues
aro
und
the
patie
nt’s
per
sona
l hyg
iene
, dre
ssin
g an
d se
lf ca
re a
bilit
y·
Groo
min
g, in
clud
ing
hair
care
and
sha
ving
·Tr
ansf
er in
/out
of c
hair/
bed
( ref
er to
M&
H). C
ompl
ete
M&
H as
sess
men
t·
Issu
es a
roun
d th
e pa
tient
’s n
utrit
iona
l int
ake,
pre
fere
nces
and
hyd
ratio
n, c
ompl
ete
nutri
tiona
lsc
reen
ing/
asse
ssm
ent,
oral
hea
lth, a
lcoh
ol in
take
·Is
sues
aro
und
the
patie
nt’s
env
ironm
ent a
nd h
ow h
e/sh
e is
abl
e to
cop
e
7.Se
nses
·Is
sues
aro
und
the
patie
nt’s
abi
lity
to e
xpre
ss s
elf i
nclu
ding
pai
n, s
enso
ry lo
ss, s
peec
h pr
oble
ms
·Sp
eech
and
com
mun
icat
ion,
firs
t/pre
ferre
d la
ngua
ge, c
onsi
der r
efer
ral t
o SA
LT·
Cons
ider
the
patie
nt’s
con
scio
us le
vel,
is h
e/sh
e or
ient
ated
and
resp
onsi
ble
for s
elf
8.M
enta
l hea
lth·
Cogn
ition
and
dem
entia
, inc
ludi
ng o
rient
atio
n an
d m
emor
y·
Men
tal h
ealth
incl
udin
g co
nfus
iona
l sta
tes,
par
anoi
d st
ates
, dep
ress
ion
and
reac
tion
to lo
ss, a
ndot
her e
mot
iona
l diff
icul
ties
·Su
bsta
nce
mis
use
(incl
udin
g tra
nqui
lliser
s or
alc
ohol
)·
Issu
es s
urro
undi
ng t
he p
atie
nt’s
leve
l of
anxi
ety,
fea
rs,
self
este
em a
nd b
ody
imag
e. H
ealth
perc
eptio
n, s
pirit
ual b
elie
fs, m
enta
l hea
lth
9.Re
latio
nshi
ps·
Soci
al s
uppo
rt an
d ne
twor
k, p
erso
nal r
elat
ions
hips
, and
invo
lvem
ent i
n le
isur
e, h
obbi
es, r
elig
ious
grou
ps·
Care
r sup
port
and
stre
ngth
of c
arin
g ar
rang
emen
ts·
Abilit
y to
car
e fo
r oth
ers
whe
re n
eces
sary
, eg
part
ner
·Is
sues
aro
und
supp
ort/r
elat
ions
hips
with
fam
ily, c
arer
s, fr
iend
s
10.
Safe
ty·
Abus
e an
d ne
glec
t. Re
fer t
o Vu
lner
able
Adu
lt Po
licie
s an
d Pr
oced
ures
)·
Issu
es a
roun
d th
e pa
tient
’s e
nviro
nmen
t and
how
he/
she
is a
ble
to c
ope
·Pu
blic
saf
ety/
haza
rds
·Co
mpl
ete
man
ual h
andl
ing
asse
ssm
ent (
risk
asse
ssm
ent)
11.
Inst
rum
enta
l Act
iviti
es o
f Dai
ly L
ivin
g·
Mea
l and
sna
ck p
repa
ratio
n, m
ake
hot d
rink,
con
side
r ref
erra
l to
OT·
Heav
y ho
usew
ork
(cle
anin
g), s
hopp
ing,
car
e of
the
hom
e·
Keep
ing
war
m·
Man
agin
g af
fairs
(fin
ance
s, p
aper
wor
k)
12.
Imm
edia
te e
nviro
nmen
t and
reso
urce
s·
Acco
mm
odat
ion
(incl
udin
g no
ise)
, hea
ting
or p
hysi
cal h
azar
ds, l
ocat
ion
and
acce
ss, s
ee S
heet
1·
Leve
l and
man
agem
ent o
f fin
ance
s an
d ne
ed fo
r ben
efit
advi
ce (r
isk
asse
ssm
ent)
·Ac
cess
to lo
cal f
acilit
ies
and
serv
ices
·W
ork,
edu
catio
n, le
arni
ng a
nd p
artic
ipat
ing
in c
omm
unity
act
iviti
es·
Tran
spor
t nee
ds, b
enef
its
FRACTURED NECK OF FEMUR
Page 30 of 45
Date Code Ongoing care, comments, interventions – all variances must be included with relevant code
Signature and Profession
Page 40 of 60 Page 21 of 60
FRACTURED NECK OF FEMUR
Page 29 of 45
Affix patient label here
POST-OP DAY 4 DATE ……………………………………… MULTIDISCIPLINARY NOTES
Medical / Nursing / Allied Health Professionals
Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist, S= Speech & Lang, Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
INTERVENTIONS AM sign
PM NIGHTsign sign INTERVENTIONS / x
NURSING PHYSIOTHERAPY 4P1 Pain controlled
Consent to treatment
4P2 Orientated
Exercise programme continued
4P3 Temperature apyrexial
Transfer practice continued
4P4 BP recorded
Gait re education
4P5 Wound dry Rehabilitation potential discussed
4P6 Continent OCCUPATIONAL THERAPY
4P7 Adequate fluids taken
Transfer assessment
4P8 Adequate diet taken
Personal ADL assessment
4P9 Fluid balanced
Heights form collected
4P10 Medication as prescribed
PHARMACY
4P11 Pressure areas (sacrum) Intact, colour
Prescription checked
4P12 Pressure areas (heels) Intact, colour
Drug therapy monitored
4P13 Personal hygiene with assistance
LIAISON NURSE
4P14 Bowels opened
4P15 Review discharge plan
4P16 Discontinue venaflow pump when mobile
INITIALS AM PM NIGHT PT OT Ph SRD
PAIN
SC
RE
EN
ING
TO
OL
Yes
No
Ple
ase
com
men
t
1.A
re y
ou in
any
pai
n no
w?
......
......
......
......
......
...C
ompl
ete
pain
sco
ring
(eg.
0-3
)
2.Is
this
pai
n ne
w?
......
......
......
......
......
...
3.D
o yo
u ex
perie
nce
pain
as
part
of a
non
goin
g pr
oble
m?
......
......
......
......
......
...
4.H
ave
you
been
see
n by
a S
peci
alis
tN
urse
. e.g
. Pai
n S
N/M
acm
illan
Nur
se/C
onsu
ltant
/
Tiss
ue V
iabi
lity/
Rhe
umat
olog
y et
c) fo
r you
ron
goin
g pr
oble
m?
......
......
......
......
......
...N
ote
prev
ious
refe
rral
; re-
refe
r if
nece
ssar
y
5.Is
sur
gery
pla
nned
?...
......
......
......
......
......
Com
plet
e ac
ute
pain
sco
re; r
efer
to S
N if
pai
n is
stil
l
prob
lem
.
6.Is
furt
her
inte
rven
tion
requ
ired?
......
......
......
......
......
...P
leas
e d
etai
l act
ion
take
n in
co
mm
ents
sec
tion.
Ple
ase
reco
rd a
ny a
ctio
n ta
ken
in th
e N
ursi
ng D
ocu
men
tatio
n:se
ek a
dvi
ce f
rom
Sp
ecia
list N
urse
if r
equi
red
Ref
erra
l to
the
Spe
cial
ist N
urse
YE
SN
O
Sig
natu
re:..
......
......
......
......
......
......
......
......
......
......
Dat
e:...
......
......
......
......
......
......
Re
Scr
een
Dat
e:...
......
......
......
.....
SCREENING TOOLS
WLE
000
01/
06S
CR
EE
NIN
G T
OO
LS
Pat
ient
Det
ails
Hos
p. N
o:N
HS
No:
Nam
e:
Add
ress
:
Pos
t Cod
e:Li
kes
to b
e kn
own
as:
Tel.
No:
......
......
......
......
......
......
......
......
.
DO
B:
Age
:
Scr
eeni
ng o
f Pat
ient
falls
, pai
n an
d n
utri
tion
mus
t be
carr
ied
out
on
adm
issi
on
to th
e S
ervi
ce a
nd a
t id
entif
ied
inte
rval
s th
erea
fter
.
STR
ATI
FY R
ISK
SC
RE
EN
ING
TO
OL
(Man
agem
ent o
f Fa
lls)
If yo
u an
swer
yes
to
any
of t
he f
ollo
win
g qu
estio
ns (
or a
re u
nsur
e) y
ou
mus
tco
mpl
ete
the
Str
atify
Ris
k A
sses
smen
t, im
plem
ent a
Pla
n of
Car
e an
d re
cord
all
eval
uatio
ns in
the
nurs
ing
docu
men
tatio
n.Y
ES
NO
1.H
as th
e pa
tient
falle
n w
ithin
the
last
3 m
onth
s?
2.Is
the
patie
nt a
gita
ted?
3.Is
the
pat
ient
vis
ually
impa
ired
to t
he e
xten
t th
at e
very
day
func
tion
is a
ffect
ed?
4.D
oes
the
patie
nt n
eeds
to u
se th
e to
ilet f
requ
ently
?
5a.
Doe
s th
e pa
tient
nee
d as
sist
ance
/sup
ervi
sion
to
get
from
sitti
ng to
sta
ndin
g?
5b.
Doe
s th
e pa
tient
nee
d as
sist
ance
/sup
ervi
sion
to m
obili
se?
Str
atify
Ris
k A
sses
smen
t com
plet
ed?
Sig
natu
re:..
......
......
......
......
......
......
......
......
......
......
Dat
e:...
......
......
......
......
......
......
.....
Re
Scr
een
Dat
e:...
......
......
......
...
Ada
pted
from
STR
ATI
FY (
Dr.
D. O
liver
- 19
97)
Page 22 of 60 Page 39 of 60
SCREENING TOOLS
WLE
000
01/
06S
CR
EE
NIN
G T
OO
LS
NU
TRIT
ION
AL
RIS
K S
CR
EE
NIN
G T
OO
L
1.M
easu
re p
atie
nt h
eigh
t...
.....
met
res
2.M
easu
re p
atie
nt w
eigh
t...
......
......
kg
3.W
ork
out t
he p
atie
nt’s
BM
I (no
rmal
20-
25)
......
......
......
.
4.W
hat i
s yo
ur n
orm
al w
eigh
t?...
......
......
kg
5.H
ave
you
unin
tent
iona
lly lo
st w
eigh
t?Ye
sN
o
6.H
ave
you
been
eat
ing
less
than
usu
al?
Yes
No
7.A
re a
ny o
f the
follo
win
g ris
k fa
ctor
s fo
r mal
nutr
ition
pre
sent
? Ti
ck a
ny th
at a
pply
:
(NB
: Pat
ient
s w
ith a
BM
I abo
ve 2
5 m
ay r
equi
re h
ealth
pro
mot
iona
l lite
ratu
re)
BMI<
20ch
roni
c di
seas
ein
fect
ion/
seps
is
wou
nds
pres
sure
sor
esun
cons
ciou
s
decr
ease
d ap
petit
eea
ting/
dige
stiv
e di
fficu
lties
inab
ility
to fe
ed in
depe
nden
tly
NBM
redu
ced
diet
ary
inta
keno
die
tary
inta
ke fo
r mor
e th
an3-
4 da
ys
diar
rhoe
a an
d/or
vom
iting
exce
ssiv
e w
eakn
ess
apat
hy/fa
tigue
Othe
r....
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
..
A “
YE
S”
resp
onse
to Q
uest
ion
5, 6
or 7
req
uire
s a
full
nutr
itio
nal a
sses
smen
tto
be
com
plet
ed N
OW
. If
you
are
unab
le t
o m
easu
re t
he p
atie
nt y
ou m
ust
com
plet
e fu
ll nu
triti
onal
ass
essm
ent.
Ful
l Ass
essm
ent C
ompl
eted
Yes
N/A
Sig
natu
re...
......
......
......
......
......
......
......
......
......
......
.. D
ate
......
......
......
......
......
......
......
....
Res
cree
n D
ate
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.
Nut
ritio
nal S
cree
ning
mus
t be
car
ried
out
on a
dmis
sion
to
the
serv
ice
and
atw
eekl
y in
terv
als
ther
eafte
r, or
if r
isk
fact
ors
deve
lop.
BO
DY
MA
SS
IND
EX
RE
AD
Y R
EC
KO
NE
R
Very
Obe
seO
bese
Ove
rwei
ght
Heal
thy
Unde
rwei
ght
FRACTURED NECK OF FEMUR
Page 28 of 45
Date Code Ongoing care, comments, interventions – all variances must be included with relevant code
Signature and Profession
Page 38 of 60 Page 23 of 60
FRACTURED NECK OF FEMUR
Page 27 of 45
Affix patient label here
POST-OP DAY 3 DATE ……………………………………… MULTIDISCIPLINARY NOTES
Medical / Nursing / Allied Health Professionals
Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist, S= Speech & Lang, Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
INTERVENTIONS AM sign
PM NIGHT sign sign INTERVENTIONS / x
NURSING PHYSIOTHERAPY 3P1 Pain controlled
Consent to treatment
3P2 Orientated
Exercise programme continued
3P3 Temperature apyrexial
Transfer practice continued
3P4 BP recorded
Gait re education
3P5 Wound dry Rehabilitation potential discussed
3P6 Continent OCCUPATIONAL THERAPY
3P7 Adequate fluids taken
Transfer assessment
3P8 Adequate diet taken
Personal ADL assessment
3P9 Fluid balanced
Heights form collected
3P10 Medication as prescribed
PHARMACY
3P11 Pressure areas (sacrum) Intact, colour
Prescription checked
3P12 Pressure areas (heels) intact Review PSPS daily, colour
Drug therapy monitored
3P13 Personal hygiene with assistance
LIAISON NURSE
3P14 Bowels opened
3P15 Review discharge plan
3P16 Discontinue venaflow pump when mobile
INITIALS AM PM NIGHT PT OT Ph SRD
PATIENT PROPERTY DISCLAIMER FORM
WM
L960
0 -
Rev
. 04-
05P
AT
IEN
T P
RO
PE
RT
Y D
ISC
LA
IME
R F
OR
M
Co
nsul
tant
/GP
:
Pat
ient
Pro
per
ty D
iscl
aim
er F
orm
War
d / A
rea:
......
......
......
......
......
......
......
......
......
......
......
......
..D
ate:
......
......
......
......
......
..
I (na
me)
......
......
......
......
......
......
......
......
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nder
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Page 24 of 60 Page 37 of 60
Co
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pert
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btai
ned.
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nder
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d th
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rope
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cide
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emai
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pert
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ded
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ekee
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ing,
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an
offic
ial r
ecei
pt o
btai
ned.
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nder
stan
d th
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ny p
rope
rty
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cide
not
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hand
in r
emai
ns m
y re
spon
sibi
lity,
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uctio
n of
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ecei
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ry o
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pert
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ld b
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To b
e re
-use
d fo
r FO
UR
adm
issi
ons
PATIENT PROPERTY DISCLAIMER FORM
WM
L960
0 -
Rev
. 04-
05P
AT
IEN
T P
RO
PE
RT
Y D
ISC
LA
IME
R F
OR
M
FRACTURED NECK OF FEMUR
Page 26 of 45
Date Code Ongoing care, comments, interventions – all variances must be included with relevant code
Signature and Profession
Page 36 of 60 Page 25 of 60
FRACTURED NECK OF FEMUR
Page 25 of 45
Affix patient label here
POST-OP DAY 2 DATE ……………………………………… MULTIDISCIPLINARY NOTES
Medical / Nursing / Allied Health Professionals
Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist, S= Speech & Lang, Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
INTERVENTIONS AM sign
PM NIGHTsign sign INTERVENTIONS / x
NURSING PHYSIOTHERAPY 2P1 Pain controlled
Consent to treatment
2P2 Remove drains Exercise programme continued
2P3 Orientated
Transfer practice continued
2P4 Temperature apyrexial
Gait re education commenced
2P5 BP recorded
Rehabilitation potential discussed
2P6 Check HB & U+E 2P7 Wound dry OCCUPATIONAL
THERAPY
2P8 Fluid balanced
Liaise with Physiotherapist
2P9 Medication as prescribed
PHARMACY
2P10 Pressure areas intact ? Colour (Sacrum, Heels)
Prescription checked
2P11 Personal hygiene with assistance
Drug therapy monitored
2P12 Bowels opened
LIAISON NURSE
2P13 Rehabilitation planned Continue discharge plan
2P14 Sub-cut cannulae removed
2P15 Sat out of bed
2P16 Taking some steps
INITIALS AM PM NIGHT PT OT Ph SRD
Con
sulta
nt/G
P:
CARE PLAN / SHEET 3
WM
L 55
35 R
ev. 1
2/02
CA
RE
PL
AN
/ S
HE
ET
3
Con
sulta
nt/G
P:
Co
ntin
uatio
nP
age
No
.
Dat
eP
rob
No
Iden
tifie
d P
rob
lem
Des
ired
Out
com
eP
resc
rib
ed A
ctio
nD
ate
for
Eva
luat
ion
Sig
n
Dat
e o
fO
utc
om
eS
ign
Pat
ient
Det
ails
Hos
p. N
o:N
HS
No:
Nam
e:
Add
ress
:
Pos
t Cod
e:
Tel.
No:
DO
B:
Age:
Page 26 of 60 Page 35 of 60
Dat
eP
rob
No
Iden
tifie
d P
rob
lem
Des
ired
Out
com
eP
resc
rib
ed A
ctio
nD
ate
for
Eva
luat
ion
Sig
n
Dat
e o
fO
utc
om
eS
ign
CARE PLAN / SHEET 3
WM
L 55
35 R
ev. 1
2/02
CA
RE
PL
AN
/ S
HE
ET
3
FRACTURED NECK OF FEMUR
Page 24 of 45
Date Code Ongoing care, comments, interventions – all variances must be included with relevant code
Signature and Profession
Page 34 of 60 Page 27 of 60
FRACTURED NECK OF FEMUR
Page 23 of 45
Affix patient label here
POST-OP DAY 1 DATE ……………………………………… MULTIDISCIPLINARY NOTES
Medical / Nursing / Allied Health Professionals Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist, S= Speech & Lang,
Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
INTERVENTIONS AM sign
PM NIGHT sign sign INTERVENTIONS / x
NURSING PHYSIOTHERAPY 1P1 Pain controlled
Consent to treatment
1P2 Order check x ray – not required for D.H.S.
Range of movement & quads
1P3 CMS to affected limb
Transfers commenced
1P4 Temperature apyrexial
Bed mobility encouraged
1P5 BP recorded
1P6 Wound dry OCCUPATIONAL THERAPY
1P7 Continue Venaflow & Asprin
Initial interview
1P8 IVI removed
Height form given
1P9 Catheter removed
PHARMACY
1P10 Fluid balanced
Prescription checked
1P11 Commence Alendronate 70mg once weekly
Drug therapy monitored
1P12 Commence Calcichew D3 forte BD
DIETITIAN
1P13 Pressure areas intact ? Colour (Sacrum, Heels)
Admission noted
1P14 Sat out of bed
LIAISON NURSE
1P15 Personal hygiene with assistance
1P16 Nutrition screening completed? 1P17 Nutrition assessment completed if necessary?
1P18 Rehabilitation Reviewed Plan discharge / transfer
1P19 Bowels opened INITIALS AM PM NIGHT PT OT Ph SRD
FRACTURED NECK OF FEMUR
Page 16 of 45
Standard Prophylaxis Venaflow + aspirin 150mg od x 35/7 If patient cannot tolerate aspirin or no venaflow available then Enoxaparin 40mg od x 10/7 + TEDs High Risk Patient Venaflow + Enoxaparin 40mg od x 10/7 SIGN guideline 62* defines as high risk a patient who has more than one of the following:- >80 years Inflammatory bowel syndrome Obesity Nephroticsyndrome Varicose Veins Polycythaemia Previous VTE Paraproteinaemia Heart failure Bechets disease Recent MI or Stroke Tamoxifen Paralysis Malignancy Reference * SIGN Guidelines Agreed with Dr H Grubb (Consultant Haematologist)
DVT Prophylaxis Guidelines for patients with Fractured Neck of Femur
Page 28 of 60 Page 33 of 60
FRACTURED NECK OF FEMUR
Page 17 of 45
Affix patient label here
ADMISSION PHASE DATE ……………………………………… Time of ward admission
INTERVENTIONS AM sign
PM sign
NIGHT Additional info sign
NURSING AP1 Pain controlled
AP2 Assessments completed
AP3 Observations completed
AP4 Gutter in-situ to affected limb
AP5 Plan of care discussed with patient and relatives
AP6 Commence pneumatic venous compression (venaflow) to both limbs if not contraindicated and commence Asprin 150mg (soluble) AM
AP7 Intravenous infusion commenced if indicated and accurate fluid balance
AP8 Pre-operative paperwork completed
AP9 Patient placed on appropriate mattress for PSPS score
Seen by Initial:
Physiotherapist Pharmacist Trauma Liaison Nurse
FRACTURED NECK OF FEMUR
Page 22 of 45
Date Code Ongoing care, comments, interventions – all variances must be included with relevant code
Signature and Profession
Page 32 of 60 Page 29 of 60
FRACTURED NECK OF FEMUR
Page 21 of 45
Affix patient label here SAFF TARGET FOR LENGTH OF STAY = 6 DAYS
OPERATION DAY DATE ……………………………………… MULTIDISCIPLINARY NOTES
Medical / Nursing / Allied Health Professionals Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist, S= Speech & Lang,
Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
INTERVENTIONS AM sign
PM NIGHT sign sign Additional info
Pre-operative OP1 Consent form checked OP2 Pain controlled OP3 Patient to wear ‘venaflow’ to theatre
OP4 IVI commenced OP5 Nil by mouth from OP6 Prepared for theatre OP7 Give usual medication Post-operative OP8 Handover from recovery OP9 Observations recorded OP10 Relatives informed OP11 IV ABS as prescribed OP12 Monitor progress if spinal anaesthetic used, inform Anaesthetist of delay of return of sensation
OP13 Drainage recorded OP14 Pain controlled OP15 Discontinue gutter splint OP16 Wound dry: Check for - Haematoma - Haemorrhage
OP17 Catheter care given OP18 Monitor colour, movement & sensation of affected limb
OP19 Medication as prescribed OP20 Check cot sides in situ PHARMACY OP21 Drug history checked Prescriptions checked Drug therapy monitored Supply ensured INITIALS AM PM NIGHT PT OT Ph SRD
FRACTURED NECK OF FEMUR
Page 18 of 45
Assessment reminder Pain score and outcome Nutritional screen Falls screen PSPS Moving and handling
Fasting instructions AM operations: no food after 12 midnight, clear fluids until 06:30am PM Operations: light breakfast 07:00am, clear fluids until 10:30am ADMINISTER USUAL MEDICATIONS UNLESS ADVISED OTHERWISE
Observations Temperature Blood pressure Pulse 02 saturation Respirations Urinalysis Blood sugar Bowels
Date Code Ongoing care comments, interventions – all variances must be included with relevant code
Signature and Profession
Page 30 of 60 Page 31 of 60
FRACTURED NECK OF FEMUR
Page 19 of 45
Affix patient label here
PRE-OP DAY DATE ……………………………………… MULTIDISCIPLINARY NOTES
Medical / Nursing / Allied Health Professionals
Code: D= Doctor, N= Nurse, PT= Physiotherapist, OT= Occupational Therapist, S= Speech & Lang, Ph= Pharmacist, SRD= Dietitian, SW= Social Worker, SN= Specialist Nurse, LN= Liaison Nurse
INTERVENTIONS AM sign
PM NIGHT sign sign INTERVENTIONS / x
NURSING PHYSIOTHERAPY
P1 Pain controlled
P2 Orientated
P3 Temperature apyrexial
P4 BP recorded
P5 Adequate fluid intake OCCUPATIONAL THERAPY
P6 Medication as prescribed
P7 Pressure areas intact
P8 Personal hygiene with assistance
PHARMACY
P9 Bowels opened
Prescription checked
P10 Rehabilitation planned
Drug therapy monitored
P11 Reason for delay recorded
P12 Health check list
P13 Consent form completed and signed
LIAISON NURSE
INITIALS AM PM NIGHT PT OT Ph SRD
FRACTURED NECK OF FEMUR
Page 20 of 45
Date Code Ongoing care, comments, interventions – all variances must be included with relevant code
Signature and Profession