DATE:
NAME:
UNIT NO:
IMMEDIATE ACUTE STROKE UNIT ASSESSMENT (must be done on arrival)
Ward
Name
Consultant
DOB
Date/time of arrival:
Unit No
The SHO/MNP on call must check that the patient is stable, that the results of bloods and CT have been seen and
documented, and that the drug chart has been done. Complete p1-5 of pathway if incomplete and initial additions.
A full clerking will be done within the next working day by the ward staff.
I have alerted the SHO/MNP to the new patient Name of nurse…. …..….signature….……….Date+time….….
I have checked the patient and the pathway
.
Name of doctor/ MNP…...signature………….Date+time………
FOR PATIENTS ARRIVING ON THE ASU DURING WEEKENDS/BANK HOLS
Patients arriving on the ASU with this pathway will not have been reviewed by a senior doctor before transfer.
During normal working days this will be done by the ward staff. Outside normal working hours patients must be
reviewed by a senior doctor (SpR, consultant, staff grade) within 12 hours of arrival to confirm the diagnosis,
make sure the pathway is complete, all results have been done and seen, patient is stable, and the drug chart is
complete.
I have alerted the SpR/SG to the new patient
Name of nurse……... .….signature…………….Date+time….….
I have checked the patient and the pathway
Name of doctor……….... signature………… .Date+time……
CONSULTANT ASSESSMENT
Name ____________
Signature_________
Date and time
_______
DATE:
NAME:
UNIT NO:
DAY 1 (to midnight) Date_______________




MEWS 6 hourly for 72 h
BM daily x3 days
Urinalysis
CT head completed

Mobilise to best capacity
within 6 hours ( tick
achieved level)
Mobilisation
Observations
Assessment
Assessments
Stimulation

Discuss effects stroke,
place, time and treatments
with patient
 Check glasses in place/ no
glasses needed
 Check hearing aid in place /
no hearing aid needed
 Dysphagia Assessment





Elimination
Weight
Nutrition
MRSA screen
Assessments as per
nursing care plan

Bilateral leg doppler
Check for catheter, remove
catheter if present
 continence assessment
Edu.
MDT
Assessment and
Referral
Continence

Outcome and actions
Highlight and hand over any
problems identified
Mews Score……………
If abnormal see actions on 72 hour
monitoring chart
Variation from pathway
problems and comments









Give reason if mobilisation
out of bed not done at least
once in the first 24 h
Walk independently
Walk with supervision
Walk with 1
Walk with 2
Transfer indep./ w 1/ w2 /hoist
Sit out of bed
Sit at the edge of bed
Sit propped up in bed
Recovery position
If drowsy wake patient up by sitting
up or changing position.
Adjust topic according to conscious
state, offer TV, books or music to
alert patients.
Encourage family to contribute.
Refered to SALT
 Yes
 No
Document risks identified:
1.
2.
3.
4.
5.
ABPI L Leg……R leg………
 Apply TEDs / TEDs not applied
(give reason)
 No catheter on arrival
 Catheter removed
 Cath. not removed (give
reason)
Time urine passed……………
Bladder scan result…………
Barthel result…………

Physio

OT


Discussion with relatives
Provide information pack
Name ____________
Signature_________
Date and time
_______
Sign
DATE:
NAME:
PROGRESS NOTES DAY 1
Time
Name ____________
UNIT NO:
Date_______________ HOUR 6 – 24
Report (all professions)
Signature_________
Signature and
professional
discipline
Date and time
_______
DATE:
NAME:
PROGRESS NOTES DAY 1
Time
Name ____________
UNIT NO:
Date_______________ HOUR 6 – 24
Report (all professions)
Signature_________
Signature and
professional
discipline
Date and time
_______
DATE:
NAME:
DAY 2 (to midnight)
UNIT NO:
Date_______________
Do
MEDICAL
NURSING
Variation from pathway
Comments and actions

Review BP,Pulse,T,O2 Sats , R/R and
prescribe appropriate treatment
 Examine for complications (DVT, PE,
Pneumonia, retention, constipation)
 Review CT head scan result
 ASPIRIN or alternative unless
haemorrhage confirmed
 Review iv/sc requirements
 Check for catheter, remove if present
 Review drugs (still nil by mouth?)
 Review blood results
 Plan discharge for minor strokes
Consider need for:
 U&Es for NBM
 Carotid Doppler if potential candidate
for endarterectomy
 APTT, lupus anticoagulant, Protein
C, Protein S, antithrombin III in
patients <50
 Echo if cardiac source of embolism
suspected
 VDRL/TPHA if indicated
 BP, HR, T, O2 Sats, SSS x4/d
 Blood Sugar x1/d
 Early Mobilisation activity record
 Dysphagia screen
 Elimination needs
 First day meeting
 Discussion with relatives
 Appointment for relatives’ clinic
PHYSIO



First assessment complete
Mobilisation discussed with key nurse
Treatment started
OT


First assessment complete
Discussed with key nurse
SALT/
swallow








First assessment complete
Normal swallow, no assessment needed
Not fit for assessment yet/ assess later
First assessment complete
No speech problem
Not fit for assessment yet/ assess later
First assessment complete
Assessment not needed yet
DC Liaison


First assessment complete
Not fit for assessment yet/ assess later
SW


First assessment complete
Not fit for assessment yet/ assess later
ESD


First assessment complete
Not fit for assessment yet/ assess later
SALT/
speech
DIETITIAN
Name ____________
Signature_________
Date and time
_______
Sign.
DATE:
NAME:
PROGRESS NOTES DAY 2
Time
Name ____________
UNIT NO:
Date_______________
Report (all professions)
Signature_________
Signature and
professional
discipline
Date and time
_______
DATE:
NAME:
PROGRESS NOTES DAY 2
Time
Name ____________
UNIT NO:
Date_______________
Report (all professions)
Signature_________
Signature and
professional
discipline
Date and time
_______
DATE:
NAME:
UNIT NO:
DAY 3 Date_______________
Do

Therapies
Nursing
Medical







Variation from pathway
Comments and actions
Signature
Review BP,Pulse,T,O2 Sats ,R/R, neuro
ob’s and prescribe appropriate treatment
Examine for complications (DVT, PE,
Pneumonia, retention, constipation)
Review iv/sc requirements
Review drugs (still nil by mouth?)
Review blood results
Update stroke checklist
Plan discharge for minor strokes
Diagnosis and plans discussed with
patient/ family
BP, HR, T, O2 Sats, R/R, neuro ob’s x4/d
Blood Sugar x1/d
Early Mobilisation activity record
Ensure patient and family aware of
diagnosis and plans
 Document mood










Physiotherapy given
Occupational therapy given
Speech therapy given / not needed
SALT swallow assessm. done/ not needed
Dietician review done/ not needed
Driving advice given/ not needed /
deferred


DC
plannin
g
DC liaison assessed / not appropriate (yet)
List for rehab wd 5/ general/
intermediate care/ not fit for transfer yet
 Referred for ESD / not appropriate (yet)
VARIATION FROM PATHWAY during the first 72 hours, assessments and actions to follow later
Time
Variation
Name ____________
Action
Signature_________
Signature
Date and time
_______