INCLUSION CRITERIA All women admitted for ALL vaginal births. 1. 2. 3. 4. 5. Discharge Criteria - copy with patient to receiving hospital - original to stay on patient chart MAR Sheet - copy with patient to receiving hospital - original to stay on patient chart 6. HOW TO USE THE This is a proactive tool to avoid delays in treatment and discharge. These are not orders, only a guide to usual orders. If already charting elsewhere, refer to the Unit specific Flow Records. Place the Clinical Pathway in the nurses clinical area of the chart. All health care professionals should fill in the master signature sheet at the front of the Pathway. Addressograph/sticker each page of the Pathway. PHYSICIANS: Add or delete tasks according to individual patient complexity, and initial all changes. HEALTH CARE PROFESSIONALS: Initial tasks as completed. Place N/A and initial any box where the task is not applicable to the patient. Additional tasks due to patient individuality can be added to the pathway in OTHER boxes and/or Progress Notes. TRANSFER PATIENTS: If patient is transferred to another hospital in Grey-Bruce, send the following: Record on Progress Notes -- actions implemented and follow up assessments. 2004-2010 Grey Bruce Health Network 1
PROGRESS NOTES: 2004-2010 Grey Bruce Health Network 2
LABOUR TRIAGE WITH ADMISSION PATIENT OUTCOME 1 2 PATIENT RECEIVED APPROPRIATE PRENATAL CARE (PREPARED FOR ADMISSION) PATIENT MEETS CRITERIA FOR ADMISSION PERFORMANCE 3 FETAL HEART RATE MEASURED BY INTERMITTENT AUSCULTATION ACTIVE LABOUR _ PERFORMANCE 4 5 FETAL HEART RATE MEASURED BY INTERMITTENT AUSCULTATION - ACTIVE LABOR IV OR SALINE LOCK STARTED FOR MEDICATION ADMINISTRATION ONLY (FIRST 2 HOURS) PATIENT OUTCOME PERFORMANCE 6 IMMEDIATE SKIN-TO-SKIN MOTHER-NEWBORN CONTACT 7 BREASTFEEDING INITIATED WITHIN 1/2 HOUR PROGRESS NOTES: 2004-2010 Grey Bruce Health Network 3
PROGRESS NOTES: 2004-2010 Grey Bruce Health Network 4
(3-24 HOURS) MATERNAL VITAL SIGNS Temperature Pulse Respiration BP Q 1 HR X 2 (If appropriate, follow post Epidural Protocol) then Q shift & PRN FUNDUS HEIGHT F - firm B - boggy ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) LOCHIA PERINEUM H - heavy R - rubra HEMORRHOIDS M - moderate S - scant/small BREASTS : S - soft F - filling E - engorged NIPPLES: SEE PROGRESS NOTES FOR COMMENT REST/SLEEP: W - well N - nap R - restless A - awake MENTAL STATUS: E - euphoric D - depressed R - receptive A - anxious BOWELS: S - suppository E - enema BM - bowel movement BLADDER: C - catheter Catheter removed @ hr V - voided @ hr See Intake & Output Sheet IV SITE CHECK: P - patent N - no redness See IV flow record PATIENT PAIN RATING < OR EQUAL TO 5 OUT OF 10 (PAIN SCALE 0-10) (Document intervention and rechecks) ASSESS CALF DAILY FOR THROMBOPHLEBITIS USING HOMANS SIGN DIETITIAN PRN BREAST ASSESSMENT / LATCH SCORE CONSULTS MEDICATIONS SOCIAL WORKER PRN CHILDREN S AID SOCIETY PRN PUBLIC HEALTH UNIT PRN LACTATION CONSULTANT PRN ASSESS MEDS FOR DISCHARGE 2004-2010 Grey Bruce Health Network 5
(3-24 HOURS) APPLY ICE PACKS CARE OF PERINEUM PERICARE Q VOIDING TREATMENTS/ INTERVENTIONS ASSIST WITH HYGIENE SITZ BATH PRN BATH AT BEDSIDE SHOWER TUB BATH APPLY WARM PACKS FOR AFTER PAIN BREAST PUMPING AS NEEDED / ENGORGEMENT REVIEWED SUTURES: Y - yes N - no LOCATION: SKIN CONDITION: R - reddened H - healing C - clean NUTRITION MOBILITY/ACTIVITY HIGH FIBER DIET ACTIVITY AS TOLERATED ENCOURAGE PARENTS TO PARTICIPATE IN NEWBORN CARE PROVIDE PARENTS OPPORTUNITY FOR BONDING AND PRIVACY ASSESS FAMILY INTERACTION PSYCHOSOCIAL SUPPORT/ EDUCATION BREASTFEEDING, INCLUDING: VIDEO, PAMPHLETS/DIARY, POSITIONING/LATCH/FREQUENCY, BURPING, NIPPLE CARE, EXPRESSION/STORAGE, FEEDING CUES, VITAMIN D FORMULA, INCLUDING: PAMPHLETS/FORMULA PREP, FREQUENCY/AMOUNT, POSITIONING, BURPING/REGURGITATION REVIEW LET S GROW PACKAGE AND COMPLETE CONSENT FORMS REVIEW COMMUNITY RESOURCES PAMPHLET VIDEOS: REVIEW "PERIOD OF PURPLE CRYING" REVIEW PATIENT PATHWAY PLANS FOR DISCHARGE DISCUSSED WITH FAMILY COMPLETE HBHC SCREENING TOOL AND CONSENT FORM DISCHARGE PLANNING HEARING SCREENING PAMPHLET REVIEWED COMPLETE HEARING SCREEN CONSENT IF EARLY DISCHARGE, ENSURE DISCHARGE PLANNING FOR 24-48 HOURS COMPLETE CHECK DISCHARGE CRITERIA DAILY PROGRESS NOTES: 2004-2010 Grey Bruce Health Network 6
PATIENT OUTCOME 8 (24-48 HOURS) MOTHER DEMONSTRATES ABILITY TO PROVIDE SAFE AND EFFECTIVE CARE AND FEEDING OF THE NEWBORN MATERNAL VITAL SIGNS Temperature Met Not Met N/A Met Not Met N/A Pulse Respirations BP Q SHIFT FUNDUS HEIGHT F - firm B - boggy ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) H - heavy LOCHIA R - rubra PERINEUM VOIDING M - moderate S - scant/small BREAST ASSESSMENT / LATCH SCORE ASSESS DAILY FOR THROMBOPHLEBITIS USING HOMANS SIGN BREASTS : S - soft F - filling E - engorged NIPPLES: SEE PROGRESS NOTES FOR COMMENT REST/SLEEP: W - well N - nap R - restless A - awake MENTAL STATUS: E - euphoric D - depressed R - receptive A - anxious BOWELS: S - suppository E - enema BM - bowel movement MEDICATIONS BLADDER: C - catheter q Catheter removed @ hr V - voided @ hr See Intake & Output Sheet IV SITE CHECK: P - patent N - no redness See IV flow record PATIENT PAIN RATING < OR EQUAL TO 5 OUT OF 10 (PAIN SCALE 0-10) (Document intervention and rechecks) RH IMMUNE GLOBULIN 300 mcg IM IF MOM RH NEGATIVE AND BABE RH POSITIVE 2004-2010 Grey Bruce Health Network 7
(24-48 HOURS) PERICARE Q VOIDING TREATMENTS/ INTERVENTIONS SITZ BATH PRN BREAST PUMPING AS NEEDED / ENGORGEMENT REVIEWED SUTURES: Y - yes N - no NUTRITION HIGH FIBER DIET MOBILITY/ACTIVITY MOTHER INITIATES SELF CARE ENCOURAGE BALANCE BETWEEN REST AND ACTIVITY PSYCHOSOCIAL SUPPORT/ EDUCATION BATH AND GENERAL BABY CARE DEMONSTRATION PRN, INCLUDING: NEWBORN ASSESSMENT, CORD & SKIN CARE, STOOL/DIAPERING, JAUNDICE, TEMPERATURE, CLOTHING, POSITIONING/SLEEPING PATTERNS REVIEW "LET'S GROW" PACKAGE REVIEW COMMUNITY RESOURCE PAMPHLETS REVIEW PATIENT PATHWAY REVIEW "PERIOD OF PURPLE CRYING" MOTHER VERBALIZES IMPORTANCE OF EMOTIONAL WELL-BEING FOLLOW UP APPOINTMENTS (PUBLIC HEALTH UNIT, DOCTOR'S OFFICE, BIRTHING UNIT) FOLLOW UP APPOINTMENT FOR LACTATION CONSULTANT IF NECESSARY COMPLETE HBHC SCREENING TOOL & CONSENT FORM DISCHARGE PLANNING HEALTH CARD FORM BIRTH REGISTRATION FORM CHILD TAX CREDIT APPLICATION MOTHERS SUPPORT GROUP BREASTFEEDING CLINIC CHECK DISCHARGE CRITERIA DAILY PROGRESS NOTES: 2004-2010 Grey Bruce Health Network 8
DISCHARGE CRITERIA MET PATIENT OUTCOME 9 ALL DISCHARGE CRITERIA MET (FROM 1-8) If all Discharge Criteria met, patient can be discharged home. ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CONSULTS DIAGNOSTICS/ LABORATORY MEDICATIONS TREATMENTS/ INTERVENTIONS NUTRITION MOBILITY/ACTIVITY PHYSICAL ASSESSMENT WITHIN NORMAL LIMITS HBHC SCREENING TOOL COMPLETED AND CONSENT FORM FAXED TO PUBLIC HEALTH UNIT SELF CARE RESUMED TO LEVEL OF NORMAL INDEPENDENCE ATTACHMENT TO INFANT PSYCHOSOCIAL SUPPORT/ EDUCATION MOTHER DEMONSTRATES: GOOD FEEDING TECHNIQUE ABILITY TO INTEGRATE KNOWLEDGE WITH SAFE AND EFFECTIVE PARENTING PRACTICES AWARENESS OF IMPORTANCE OF HER PHYSICAL AND EMOTIONAL WELL BEING IN HER ABILITY TO COPE WITH NEWBORN AND HER ROLE AS A MOTHER AWARE OF COMMUNITY-BASED RESOURCES AVAILABLE FOR SUPPORT DISCHARGE PLANNING NOTIFY PHYSICIAN FOR ACL ORDER IF MOTHER MEETS DISCHARGE CRITERIA BUT BABY DOES NOT FOLLOW-UP APPOINTMENT WITH PHYSICIAN DISCHARGE TIME 2004-2010 Grey Bruce Health Network 9