Head Injury Pathway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PATIENTS 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 14 and abov

2、e.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 14-152. History of loss of consciousness3. Skull fracture, on X-ray clinically4. Neurological signs and symptoms5. Vomiting6. 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.头痛Exclusion Criteria for Hea

3、d 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 <143. 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 episode可在住院的任何一天开始启用2. How to use

4、 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 bydoctors) Enter additional orders in the space provided, indicate date & time of entry Write your name, MCR No. and sign on the daily Pathway, after completi

5、ng 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 problem with the document

6、ation of thePathway. Put a “ ” in the if action/intervention is done Put a “-” in the if not applicable Put an “×” in 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咨询医生/个案主管，如果有任何路径文件的问

7、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 / doctors ward round Discuss the following with the Multidisciplinary Team:i) Plan of care iv) Discharge plansii) Critical events v) ELOSiii) P

8、rogress of the patient vi) Patient/familys 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. ELOS6.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 Document the reason(s) for exiting from the P

9、athway 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 coordinatepatient care.ii) It is not intended or construed as the

10、 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 Patients 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Date日期 : _(Admission Day入院日期)Emergency Department急诊室Unit单位

11、Ward病区Bed床号Class级别Standard Order标准医嘱(in theif done/order)执行后或开医嘱则在中打Nursing Intervention护理处置( in theif 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 more after injurySuspected open or depressed skull fractureAny sign of basal

12、skull fractureTwo or more episode of vomitingAge, 65 years or olderMore than 30 mins of amnesia prior to injurySevere mechanism of injury: RTA Fall from more than 1m Fall from 5 or more stairsLook for associated cervical 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

13、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

14、 Doctor: 医生签字_Name of Doctor:医生名字 _MCR No: _Time:时间_Shift班次Name and Signature of Staff Nurse护士签名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Affix Patients Sticky Label He

15、reClinical Pathway for Minor Head Injury ( DRG 052 )轻度头部损伤临床路径Date : _(Admission Day入院日)UnitWardBedClassStandard Order(in theif done/order)Nursing Intervention( in theif done, X if not done, - if not applicable）Patient clerked by doctor within 1hour医生在1小时内处理病人Careful assessment for cause of fall and

16、 home circumstances, particularly in the elderly仔细检查跌倒原因和家庭环境，特别是老人FBC and Renal Panel (>65 yrs old if indicated)血常规、肾功能（65岁以上老人需要时）Toilet and suture if required清创、缝合（需要时）Nil by mouth till review禁食直至再次评估后Intravenous therapy (If necessary)静脉输液（需要时） Hourly head chart x 12 hours每小时头部记录单x 12小时Doctor

17、informed at_hrs.通知医生时间：Clerked by Dr _ at _处理医生： 时间：Hourly parameters including CLC, informdoctor if GCS < 14每小时生命体征包括意识，GCS < 14时通知医生Pain assessment and management疼痛评估、处理Fall prevention interventions refer toChecklist跌倒预防措施按检查单Head Injury advice, refer PFE record头部损伤宣教，根据宣教记录Cervical collar (

18、if evidence of neck injury)颈托（如果有颈部损伤的迹象）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: _Name of Doctor: _MCR No: _Time: _ShiftName and Signature of Staff NurseAdditional Orders添加医嘱(Indicate Date and Time)Multidisciplinary Team Notes多

19、学科团队记录Additional Orders(Indicate Date and Time)Multidisciplinary Team NotesAffix Patients Sticky Label HereClinical Pathway for Head InjuryDate : _(Day 1第1天)UnitWardBedClassStandard Order(in theif done/order)Nursing Intervention( in theif done, X if not done, - if not applicable）Assess fitness for d

20、ischarge评估是否能出院Yes是 No否Discharge criteria出院标准1. Vital signs stable for 24 hours2. No CSF leak3. Patient is able to tolerate diet with no vomiting4. Patient/carer able to provide safe care outside hospital1.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 an

21、d CT scan films for reportingX-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疼痛评估和处理Fall prevention interventions refer toChecklist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 Pla

22、nning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: _Name of Doctor: _MCR No: _Time: _ShiftName and Signature of Staff NurseAdditional Orders(Indicate Date and Time)Multidisciplinary Team NotesAdditional Orders(Indicate Date and Time)Multidisciplinary Team NotesAff

23、ix Patients Sticky Label HereClinical Pathway for Head Injury头部损伤临床路径Date : _(Day2第2天)Delayed DischargeUnitWardBedClassStandard Order(in theif done/order)Nursing Intervention( in theif done, X if not done, - if not applicable）Assess fitness for discharge评估能否出院Yes是 No否Discharge criteria出院标准1. Vital s

24、igns stable for 24 hours2. No CSF leak3. Patient is able to tolerate diet with no vomiting4. Patient/carer able to provide safe care outside hospital1.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 reportingX-光片、CT片报告6 hourly paramet

25、ers including CLC每6小时监测生命体征、意识Pain assessment and management疼痛评估和处理Fall prevention interventions refer toChecklist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Signature of Doct

26、or: _Name of Doctor: _MCR No: _Time: _ShiftName and Signature of Staff NurseAdditional Orders(Indicate Date and Time)Multidisciplinary Team NotesAdditional Orders(Indicate Date and Time)Multidisciplinary Team NotesAffix Patients Sticky Label HereVARIANCE RECORD FORM变异记录单UNIT单位CLASS级别WARD病房BED床号 Date

27、 of Admission入院日期 : _Consultant-in-charge : _Instructions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 patients 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

28、，将此表交案例经理Key Indicators :关键指标 Length of stay住院日 Readmission再入院< 15 days15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

29、 CCF慢性心衰 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Principal Diagnosis 主诊断: Minor Head InjuryPrincipal Procedure主要的处置 : _Medically fit for discharge on 出院适用药物: _Discharged on出院时间 : _D

30、ischarged to 出院去向: Home家 Rehab. Services康复设施 Nursing Home护理之家 Others其它 : _CT, Brain Scan done on 做脑部CT时间: _Skull X-ray done on :做头部X线时间 _Blank Page空白页Affix Patients Sticky Label HerePATIENT AND FAMILY EDUCATION (Head Injury Management )病人和家庭教育(To be done as early as the day of admission/within 48 ho

31、urs)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Reason原因 : _Family Participation

32、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 / ProcessKnowledge of MedicationCare of Devices (pls specify) :Pain / Comfort MeasureDiet ModificationOthers (pls specify) :Assessed by 评估者: _ _ _Signature签字 De

33、signation & 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 to show evidence of understanding and k

34、nowledge 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 Emergency Department immediately if the fo

35、llowing 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 behaviour 定向障碍，模糊，行为过激_ Fits or any kin

36、d 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_ Action and