AFFIX IDENTIFICATION LABEL
ROYAL CHILDREN'S HOSPITAL MELBOURNE, AUSTRALIA
Date: …………..Time: …….………..Ward/Unit: ……………….……..…………..Consultant:…………………. Interpreter required? Yes No Language: Details on ID label correct? Medical Certificate required? Yes Yes No No
Parents/guardians staying at: Contact numbers:
Home circumstances/support mechanisms in place/required:
Support visitors: Isolation precautions:
• Protective isolation during transplant commences when the neutrophil count drops below 500. For some children this may mean from the time of admission to the RCH. Protective isolation means parents must wear a gown. All other people entering the room must wear a mask. In addition other people must wear a gown for direct patient contact. Date commenced: Protective isolation may cease when the child has a neutrophil count >500 for 3 consecutive days with at least one neutrophil count of 1000. From this time until discharge, all people entering the room must wear gowns for direct patient contact. Date commenced:
•
Prior to and following the period of protective isolation, the child may leave the room to exercise in the “Bat Cave”. This is most appropriate when it is quiet. It is not necessary for the child to wear a mask in the “Bat Cave”
Does anyone at home smoke? Yes Resources given? DIAGNOSIS: Relevant Past History: Yes
No Who:
Are they interested in help to stop? Yes nurse advice doctor advice
No What resources? written materials
Allogeneic Stem Cell Transplant Clinical Path MR 96z
TYPE OF SCT.
Current Medications: include method of administration
ALLERGIES: Recorded on medication & anaesthetic chart Red band attached Food allergy: Kitchen notified
Special interests / needs / disabilities: Disability profile completed (MR 112 )
Usual diet:
Nasogastric tube insitu
Yes
No
If yes, date of insertion
If NG tube inserted on admission document as variance. Document size of tube, nostril inserted, distance inserted and location verification
CVC care:
HICKMAN® dressing as per RCH protocol: If no, describe: Port insitu: Yes No
Yes
No
If yes, date of last flush. Height
Weight Continue admission over page.
= Refer to BMT guideline folder (located at nurses station two)
HICKMAN and BROVIAC are registered trade marks of C.R. Bard, Inc.
Nursing Admission (continued…)
CONSULTATIONS
INVESTIGATIONS ASSESSMENT / TREATMENT Intake/Output
Medical admission complete Nursing history complete Other Bloods collected as per protocol Baseline pre SCT investigations completed as per protocol 4/24 TPR, BD BP or as clinically indicated Assess Intake (Oral/NG/IV) and Output (Vomiting/ Diarrhoea/Constipation) and maintain strict fluid balance chart as per guidelines Give intravenous fluids as ordered Weigh as per guidelines Urinalysis Give oral medications as ordered Assess CVC site for sign of infection, swelling, ooze, intact dressing and pain. (Document presence of these and action as variance) PM Attend the following PM HICKMAN® line change HICKMAN® line flush HICKMAN® dressing change Needle change Assess skin. Document rash or altered skin integrity and action taken as variance. Assess Oral mucosa. Document Oral Assessment Guide Score in box Oral care as per protocol Perineal care as per protocol Child/Family information needs identified and addressed. Document discussions on variance
page
CVC care
Hygiene
Education Other Patient specific needs Who attends care
Isolation precautions Bath Hydraderm Nasal spray Nurse / Carer Mouthcare Nurse / Carer Bike/Activity Nurse / Carer Assessment parameters within normal range. (Include vital signs, CNS status, pain, CVC assessment, oral mucosa, perineum, skin, hydration, urinalysis) or documented as outlined above. Blood results checked and appropriate action taken Patient/Family understand plan of care Commence conditioning
Date: Time: Print name, sign, designation: Additional notes written in UR
Nurse / Carer Nurse / Carer
OUTCOMES
PROGRESS CRITERIA Nurse
= Refer to BMT guideline folder (located at nurses station two)
HICKMAN and BROVIAC are registered trade marks of C.R. Bard, Inc.
Allogeneic Stem Cell Transplant Pre Transplant phase Date:
INVESTIGATIONS
eg FBE U+Es LFT Clotting Glucose Xmatch CMV Blood Cultures Antibiotic levels Xray Other
AFFIX IDENTIFICATION LABEL
Day of BMT:
Test time initial Test time initial
ND
CONSULTATIO NS
AM
PM
Resident/Registrar Fellow/Consultant Dietitian Other 4/24 TPR, BD BP or as clinically indicated Assess pain. Document score and action on observation chart Assess CNS status Assess Intake (Oral/NG/IV) and Output (Vomiting/ Diarrhoea /Constipation) and maintain strict fluid balance chart as per guidelines Give intravenous fluids/chemotherapy as ordered Weigh as per guidelines Urinalysis once per shift or as clinically indicated Document below on AM shift, route of medication administration that can be given orally. On PM shift, document alteration in route as variance. Orally via nasogastric tube , Intravenously NG tube in situ If NG tube inserted, replaced or removed document as variance.
Document size of tube, nostril inserted, distance inserted and location verification
ASSESSMENT / TREATMENT Intake/Output
Nasogastric Hygiene
NG tube position confirmed as per guidelines NG feeds given and managed as per decision making tree Assess skin. Document rash/altered skin integrity and action taken
as variance.
Activity Education Other Patient specific needs CVC care
Document Oral Assessment Guide Score in box on AM shift Oral care as per protocol Perineal care as per protocol Daily bath or as specified on protocol Exercise bike ridden (if > 6) Document time and duration on obs chart Child/Family information needs identified and addressed. Document discussions on
variance page
Isolation precautions Assess CVC site for sign of infection, swelling, ooze, intact dressing and pain. (Document presence of these and action as variance) ND AM PM Attend the following HICKMAN® line change HICKMAN® line flush HICKMAN® dressing change Needle change Circle person attending Bath Nurse / Carer Nasal spray care on AM shift. Hydraderm Nurse / Carer Mouthcare Document change on other Bike/Activity
shift as variance
ND
AM
PM
Who attends care
Nurse / Carer / NA Nurse / Carer / Patient Nurse / Carer
OUTCOMES
PROGRESS CRITERIA
Assessment parameters within normal range. (Include vital signs, CNS status, pain, CVC assessment, oral mucosa, perineum, skin, hydration, urinalysis) or documented as outlined above. Blood results checked and appropriate action taken Patient/Family understand plan of care Day 0.
Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Additional notes written in UR Additional notes written in UR Additional notes written in UR
ND AM PM
= Refer to BMT guideline folder (located at nurses station two)
HICKMAN and BROVIAC are registered trade marks of C.R. Bard, Inc.
Variance Tracking Record
WHY ? eg: Parents not in attendance WHAT DID YOU DO ABOUT IT ? eg: Handed over to next shift OUTCOME eg: Parents still require orientation SIGNED
= Refer to BMT guideline folder (located at nurses station two)
HICKMAN and BROVIAC are registered trade marks of C.R. Bard, Inc.
DATE
TIME 24 hr clock
WHAT OCCURRED ? eg: Orientation not given to parents
INSTRUCTIONS for USE
• • •
•
Record date and time as appropriate at the top of each column Each shift the nurse should complete the column & sign below in the space provided. TICK = item of care given as per path; “n/a” = care is not applicable to this patient at this time OR “VAR” = patient care or condition has varied from the path. The details are written on the Variance Tracking Record above If you have any queries please contact the Care Coordination Manager in Clinical Support Services ext / pager 6956
Allogeneic Stem Cell Transplant Post Transplant phase Date:
INVESTIGATIONS
eg FBE U+Es LFT Clotting Glucose Xmatch CSA CMV Blood Cultures Antibiotic levels Xray Other
AFFIX IDENTIFICATION LABEL
Day of BMT:
Test time initial Test time initial
ND
CONSULTATIO NS
AM
PM
Resident/Registrar Fellow/Consultant Dietitian Other 4/24 TPR, BD BP or as clinically indicated Assess pain. Document score and action on observation chart Assess CNS status Assess Intake (Oral/NG/IV) and Output (Vomiting/ Diarrhoea /Constipation) and maintain strict fluid balance chart as per guidelines Give intravenous fluids as ordered Weigh as per guidelines Urinalysis once per shift or as clinically indicated Document below on AM shift, route of medication administration that can be given orally. On PM shift, document alteration in route as variance. Orally via nasogastric tube , Intravenously NG tube in situ If NG tube inserted, replaced or removed document as variance.
Document size of tube, nostril inserted, distance inserted and location verification
ASSESSMENT / TREATMENT Intake/Output
Hygiene
NG tube position confirmed as per guidelines NG feeds given and managed as per decision making tree Assess skin. Document rash/altered skin integrity and action taken
as variance.
Activity Education Other Patient specific needs CVC care
Document Oral Assessment Guide Score in box on AM shift Oral care as per protocol Perineal care as per protocol Daily bath Exercise bike ridden (if > 6) Document time and duration on obs chart Child/Family information needs identified and addressed. Document discussions on
variance page
Isolation precautions Insuflon inserted/resited each 7 days. If other than this document as variance. Assess CVC site for sign of infection, swelling, ooze, intact dressing and pain. (Document presence of these and action as variance) ND AM PM Attend the following HICKMAN® line change HICKMAN® line flush HICKMAN® dressing change Needle change Circle person attending Bath Nurse / Carer Nasal spray care on AM shift. Hydraderm Nurse / Carer Mouthcare Document change on other Bike/Activity
shift as variance
ND
AM
PM
Who attends care
Nurse / Carer / NA Nurse / Carer / Patient Nurse / Carer
OUTCOMES
D/C PLANNING & CRITERIA
Assessment parameters within normal range. (Include vital signs, CNS status, pain, CVC assessment, oral mucosa, perineum, skin, hydration, urinalysis) or documented as outlined above. Blood results checked and appropriate action taken Patient/Family understand plan of care Discharge booklet given and checklist commenced when child: has a neutrophil count >500 and is tolerating oral medications. Discharged as per guidelines.
Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Additional notes written in UR Additional notes written in UR Additional notes written in UR
ND AM PM
= Refer to BMT guideline folder (located at nurses station two)
HICKMAN and BROVIAC are registered trade marks of C.R. Bard, Inc.
Variance Tracking Record
WHY ? eg: Parents not in attendance WHAT DID YOU DO ABOUT IT ? eg: Handed over to next shift OUTCOME eg: Parents still require orientation SIGNED
= Refer to BMT guideline folder (located at nurses station two)
HICKMAN and BROVIAC are registered trade marks of C.R. Bard, Inc.
TIME 24 hr clock
WHAT OCCURRED ? eg: Orientation not given to parents
INSTRUCTIONS for USE
• • •
•
Record date and time as appropriate at the top of each column Each shift the nurse should complete the column & sign below in the space provided. TICK = item of care given as per path; “n/a” = care is not applicable to this patient at this time OR “VAR” = patient care or condition has varied from the path. The details are written on the Variance Tracking Record above If you have any queries please contact the Care Coordination Manager in Clinical Support Services ext / pager 6956
= Refer to BMT guideline folder (located at nurses station two)
HICKMAN and BROVIAC are registered trade marks of C.R. Bard, Inc.
DATE