PHILIPPINE HEART CENTER East Avenue, Quezon City · PDF file · 2004-12-31episodes...

PHILIPPINE HEART CENTER

East Avenue, Quezon City

DEPARTMENT OF PEDIATRIC CARDIOLOGY

CONGENITAL HEART DISEASE – TETRALOGY OF FALLOT CLINICAL PATHWAY OPEN HEART SURGERY – TOTAL CORRECTION

INCLUSION CRITERIA

Age: 1-18 years of age

For Philhealth Z-Benefit Program : 1 – 10 years + 364 days ONLY

Patients diagnosed with either Tetralogy of Fallot OR Ventricular Septal Defect and Pulmonic Stenosis, moderate to severe EXCLUSION CRITERIA TOF with other associated major CHD (eg. AVSD, Absent pulmonic valves, etc). Patients with Chromosomal abnormalities except Downs Syndrome

Check for the following risk factors:

1. Pulmonary Valve Annulus (Acceptable Z score by BSA > - 3)

If PVA Z score < -3 Right and Left Pulmonary Artery Sizes (Acceptable Z score by BSA > -

2)

RPA: Z < -2 and / or LPA: Z < -2

4. Check PA supply: Antegrade flow from RV

With Collaterals: MAPCA’s

With Previous BTS Date : ___________________

2. RPA + LPA: Descending Aorta Ratio McGoons Index (Adequate > 1.5); Nakata Index (Adequate > 150)

McGoons < 1.5 and / or Nakata score < 150

5. Check CBC : Acceptable Hematocrit (Hct) 50 – 60 mm/dl

Hct less than 48 mg/dl

Hct more than 65 mg/dl

NOTE: *If at least one risk factor (#1 – 4) is present, consider Cardiac Catheterization or CT angiography to confirm adequacy of anatomy before surgery or

proceed to Blalock Taussig Shunt (BTS) Clinical Pathway. *Correct hematologic problem if # 5 is present before surgery.

PATIENT’S NAME ______________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME

DATE OF BIRTH ________________ MM/DD/ YYYY

SEX: ( ) M ( ) F

PHILHEALTH NUMBER ___________________________ ( )Father ( )Mother

Room No. HOSPITAL NUMBER

DAY 1: Pathway Activated: Date:________Time:________Pathway Terminated: Date:________Time:________(Day 1-1) 1

CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Subjective complaints hypercyanosis hypoxic spells loss of consciousness episodes of active bleeding phlebotomy (if any) seizure Others (eg. Allergy, etc)

_____________________________ _____________________________

Vital signs:

BP: HR : RR:

Temp: Wt: Ht:

BSA: BMI:

O2 sat:

Latest Clinical Findings: Skin: __pale __pink__ jaundice __cyanotic Pupils (size/reactivity): ________________ Conjunctiva:__pale__pink___suffused Chest Expansion:____________________ Lungs (breath sounds):_______________ Heart (murmurs):____________________ Abdomen:__________________________

Liver edge:_______________________ Peripheral and Central pulses:__________ Extremities: ___Warm ___Cold CRT: ___ <2sec ___> 2 sec Neuro exam:

Admit to room __________ under the service of: Pediatric Cardiologist: ______________________ TCVS: ___________________________________ CV Anesthesia : ___________________________ CV Intensivist: ____________________________ Pediatric Pulmonologist:____________________

Please secure consent for Admission

Please accomplish PHC admitting history and PE database

Monitor vital signs: Record input and output every 8hrs

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Request for the following diagnostics: Chest X-ray (PA-L) (AP-L) Electrocardiogram (15L-ECG) 2D Echocardiogram with Colorflow doppler ABG CBC with platelet Protime (PT) > 70 %; INR < 1.5 PTT < 45 secs Creatinine Serum Na, K, Ca Blood Typing (save blood for crossmatching) Request for Intraoperative TEE. Refer to:

_______________________________________ Bleeding Time (if platelet < 100,000/mm

3)

Medications: Propranolol_____________________________ Others ___________________________________________

________________________________

Prepare the following blood products: Cryoprecipitate ____________________ units Fresh Whole blood / Packed RBC ______ units Platelet concentrate ________________ units Fresh Frozen Plasma ________________ units

(Refer to Blood Conservation Program of the Hospital)

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PATIENT’S NAME ____________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME


SEX: ( ) M ( ) F

PHILHEALTH NUMBER __________________________ ( )Father ( )Mother


DAY 1: Date: ___________________________________Time:____________ (Day 1- 2) 2

CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE

SURGICAL ORDERS Schedule TOF Correction on _______________ Procedure explained to family Consent secured and signed Consent for blood transfusion secured and signed

Insert Heplock ________________________

Refer to other subspecialty services (if needed indicate specialty and name of specialist):

a. ______________________________________ b. ______________________________________ c. ______________________________________ (Please use separate referral form for additional orders

of the specialist)

Diet/Nutrition:____________________________ ________________________________________

Activity/Safety (See nursing safety protocol/Fall prevention protocol) _______________________

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NURSING ASSESSMENT: Braden Risk Score: _____________ General Pain Assessment: _____________ NIPS – FACES: _____________ Fall Risk Score: _____________

INTERPRETATION:

Provide Psychosocial/Spiritual support to: Play Therapy appropriate for age Inquire about the need for psychologic

evaluation (CHEERS protocol) Inquire about spiritual need (if needed)

Patient/Family Education: Disease process, Operative Update and Methods Explain procedure and get consent for surgery

and blood transfusion Discuss Clinical Pathway with Family

PARENTS/GUARDIAN UNDERSTOOD, VERBALIZED,

CONSENTED AND SIGNED THE TOF CARE PLAN ( ) Yes ( ) No

Schedule for surgery on ______________________

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OUTCOME GOALS: Vital signs stable Blood products available Pathway and procedures clear to

parents and/or guardian Risk of surgery explained to

parent/guardian and understood Consent for TOF correction signed

( ) Y ( ) N ( ) Y ( ) N ( ) y ( ) N ( ) Y ( ) N ( ) Y ( ) N

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DISCHARGE PLANNING: Estimated date of discharge ____________ Prepare for TOF Correction Defer TOF surgery

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ACTIVATED BY: ACKNOWLEDGED BY: _________________________ Signature over Printed Name PEDIA CARDIO CONSULTANT/FELLOW Date:_________Time:______

________________________ Signature over Printed Name TCVS CONSULTANT/FELLOW Date:_________Time:______

_____________________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (AM SHIFT) Date:_________Time_______

___________________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (PM SHIFT) Date:_________Time_______

VARIANCE CODES (SEE PAGE 5)





PATIENT’S NAME _____________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME


SEX: ( ) M ( ) F



DAY 2: Pathway Activated: Date:________Time:________ Pathway Terminated: Date:_________Time:_________(Day 2-1) 3

CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat

Latest Clinical Findings: Urine Output: _____ CTT output: ______ Skin: __pale __pink __jaundice __cyanotic Pupils (size/reactivity): ________________ Conjunctiva (pale/pink): ______________ Chest Expansion: ____________________ Lungs (breath sounds): _______________ Heart _____________________________ ___________________________________ ___________________________________ Abdomen: __________________________

Liver edge: _______________________ Peripheral and Central pulses: __________ Extremities: Warm / cold ______________ CRT: ___ <2sec ___> 2 sec Neuro exam: Laboratory Findings: Hemoglobin (Hgb): _____ Hct: _____ WBC: ____ Segmenters: _____ Lymphocytes: ____ Eosinophils: _____ Basophils: ______ Actual Platelet count: ____ Creatinine: _______ PT:_______ PTT: INR ______ % ______ Serum Na ______ K ______ Ca _______ Blood Type: _______ Ancillary Procedures: ECG _______________________________ __________________________________ 2D Echocardiogram___________________ ___________________________________ ___________________________________ ___________________________________ Chest -XRay ___________________________________ ___________________________________

PREOPERATIVE ASSESSMENT

Monitor vital signs, intake and output every ___ hours

Follow up the following laboratory results: Chest X-ray (PA-L) (AP-L) 15-lead EKG 2D Echocardiogram with CFDS CBC with platelet Protime (PT) > 70 %; INR < 1.5, PTT (< 45 secs) Bleeding Time (if platelet is < 100,000) Creatinine Serum Na, K, Ca Blood Typing (save blood for crossmatching)

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Check availability of the blood products Cryoprecipitate _______________ units FWB / PRBC __________________ units Platelet concentrate ___________ units Fresh Frozen Plasma ___________ units

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PREOPRATIVE ANESTHESIA EVALUATION AND MEDICATION:

Patient is scheduled for TOF Correction on: Date ______________ Time _________ am/pm

Secure consent for anesthesia Hair clipping Routine oral / body hygiene Start IV Fluids: Date_______ Time _____am/pm

Fluids D5 0.3% NaCl D5 LRS / NSS D5 IMB Plain LRS / NSS

Flow Rate _____________________________cc/hr

IV Cannula G 24 G 20 G 22 G 18

Other Materials Microset

Perfusor extension tubings 3 way stop cock Syringe pump Soluset

OXYGEN Therapy:

None Nasal Cannula Mask

Flow Rate 1 L 2 L 3 L 4 L

Fasting Schedule

AGE Fasting Time

Date/ Time Solids

* Clear Liquids

**

<6mos 4hrs* 2 hrs

6-36mos 6hrs* 3 hrs

>36mos 6hrs+ 3 hrs * Milk Formula, breastmilk

** Apple Juice, water, glucose water + Toast, Biscuits, cookies

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SEX: ( ) M ( ) F



DAY 2: Date: ___________________________________Time:____________ (Day 2- 2 ) 4

CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Cardiac Catheterization (Hemodynamic Study Data and Angiogrography )

NO

YES (if yes, please complete the following data):

Date Done:______________________ A. Diagnosis : ________________________________ ________________________________ ________________________________ B. Angiogram : 1. With Collaterals : ( ) Y ( ) N 2. Adequate pulmonary artery (PA)

sizes ( ) Y ( ) N 3. Other Associated Lesions

______________________________ ______________________________ C. Hemodynamic Data :

1. Cardiac Output : _____________ 2. Mean RV Pressure : ___________ 3. Mean LV Pressure :___________ 4. RVOT Gradient :______________

Pre-medications

Medication Dose

Route* Date/

Time

No Premeds

Atropine SO4

Midazolam

Diphenhyrdamine

Meperidine HCl

Morphine SO4

Nalbuphine HCl

Methylprednisolone

Others__________ * IM/IV/PO

Antibiotic prophylaxis: Vancomycin

________________________________________ ________________________________________

Current IDS recommendation ________________________________________ ________________________________________

Others ________________________________________ ________________________________________

Please check vital signs before and every 15 mins after giving premeds

Maintain Body Temperature between 360C – 37

0C

Please check availability of Blood Components

Patient must be at the OR Date: ____________ Time: ____________

Diet / Nutrition ____________________________________________ ____________________________________________

Activity/Safety: (See nursing safety protocol/Fall prevention protocol) __________________________

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PREOPERATIVE ASSESSMENT Provide Psychosocial/Spiritual support to:

Inquire about the need for psychological evaluation (CHEERS protocol)

Inquire about spiritual need (if needed)

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DATE OF BIRTH ______________ MM/DD/ YYYY

SEX: ( ) M ( ) F

PHILHEALTH NUMBER _________________________ ( )Father ( )Mother


DAY 2: Date: ___________________________________Time:____________ (Day 2-3) 5

CLINICAL NOTES PHYSICIAN’S NOTES SIGNATURE VARIANCE

Patient/Family Education: Disease process Explain procedure and get consent for surgery and

blood transfusion Discuss Clinical Pathway Pre-operative Orientation (c/o OR/SICU Personnel)

to Patient / Parents and / or significant family members

Health Education: Utilizing Methods by Nursing Division

PARENTS/GUARDIAN UNDERSTOOD, VERBALIZED,

CONSENTED AND SIGNED THE TOF CARE PLAN ( ) Yes ( ) No

Proceed with surgery on ____________

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NURSING ASSESSMENT Braden Risk Score: ___________ General Pain Assessment: ___________ NIPS – FACES: ____________ Fall Risk Score: ___________

INTERPRETATION:

OUTCOME GOALS: Vital signs stable Blood products available Pathway and procedures clear to

parents and/or guardian Risk of surgery explained to

parent/guardian and understood Consent for TOF correction

signed

( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N

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DISCHARGE PLANNING: Estimated date of discharge ____________ Prepare for TOF Correction Defer TOF surgery

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ACTIVATED BY: ACKNOWLEDGED BY: ____________________________ Signature over Printed Name PEDIA CARDIO CONSULTANT/FELLOW Date:_________Time:______

____________________________ Signature over Printed Name ANESTHESIA CONSULTANT/FELLOW Date:_________Time:______

___________________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (AM SHIFT) Date:_________Time______

__________________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (PM SHIFT) Date:___________Time______

VARIANCE CODES

A. PATIENT / FAMILY B. HEATH PROVIDER C. PHC SYSTEMS D. OUTSIDE PHC

1. Patient’s medical condition 1.Medical order 1. Results / Data availability 1. Condition / Transportation

2. Patient/Family decision 2. Provider’s decision 2. Delay in Test Results 2. Home care availability

3. Patient/ Family availability 3. Provider’s response 3. Delay in procedures 3. Other reasons

4. Noncompliance to treatment 4. Other reasons 4. Cancellation of procedures

5. No funds 5. Delay in patient transfer

6. Other reasons 6. Supplies / Equipment related

7. Appointment Availability

8. Weekend / Holiday

9. Other reasons





PATIENT’S NAME ___________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME

DATE OF BIRTH _______________ MM/DD/ YYYY

SEX: ( ) M ( ) F



DAY 3: OR DAY Pathway Activated: Date:_______ Time:_______ Pathway Terminated: Date:______Time:______(Day 3- 1) 6

1st 6 HOURS POST SURGERY CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE

Date of Surgery : ____________________ Surgeon and Anesthesia Notes Total Ischemic Time: ___________________ Total Bypass Time : ____________________ Total length of procedure:______________ Intraoperative Condition:

OFF BYPASS

Prior to transport

VITAL SIGNS / PE

BP (S/D)VP

HR

CVP

PAP

LAP

RVP

Temp

U.O

Pupils

Skin

Lung Comp

Bleeding

Medications

Dopamine

Dobutamine

Epinephrine

Milrinone

Levophed

NTG

Ca Gluc

Iloprost

Salbutamol

Labs

Hct

Na

K

Ca

ACT

ABG

Blood Transfusions

PRBC

FWB

PLT Conc

FFP

Cryo Ppt

PROCEDURE/DONE: __________________________________________ __________________________________________

ADMIT TO SURGICAL ICU Monitor vital signs and review of systems

every 15 minutes for the first two hours then every 30 minutes for 2 hours then hourly thereafter

Maintain the following VS: BP: ______ CR and rhythm: _______ RR: ______ O2 sat:______ Temp: _____

Hook to Capnograph Place on temperature regulatory device Maintain UO: ______cc/hr CVP: _______

CTT (< 2cc/kg/hr): _______________

Laboratory Tests (indicate time): ABG, lactate and Serum electrolytes (Na, K, Ca,

Mg) ________________________ CBC with APC ________________ PT, PTT _____________________ CXR(portable)________________ 2D Echocardiogram __________ Venous saturation____________ Others______________________

OXYGEN Therapy: Ventilatory Support

FiO2 RR

TV / PIP PEEP

Total Fluid Requirement (TFR) : 750 -1000 cc/BSA (1.2 – 2 cc/kg/hr)___cc/day

Cardiac Supports (dose:concentration) Dopamine: (____:_________)__________cc/hr NTG: (____:_________)__________cc/hr Milrinone: (____:_________)__________cc/hr Others:

________(____:________)__________cc/hr ________(____:________)__________cc/hr

CVP Line: ________________________cc/hr A-line: ________________________cc/hr Medication Line: ____________________cc/hr

TOTAL Rate: _______________________cc/hr

On-going blood products: 1. ________________________________________ 2. ________________________________________

Medications Calcium gluconate:________________________ H2-blocker/Proton Pump Inhibitor:___________

_______________________________________ Vancomycin:_____________________________ Sedative:________________________________ Others:_________________________________

________________________________________

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PATIENT’S NAME ___________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME


SEX: ( ) M ( ) F



DAY 3 Date: ___________________________________Time:____________ (Day 3- 2) 7

1st 6 HOURS POST SURGERY CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE

Other intraoperative Conditions Neurologic

Renal

Gastrointestinal

______________________________ Intraoperative Transesophageal Echocardiogram (IOTEE) Findings: General Assessment upon transport to SICU:

Stable, no inotropic support

Stable with 1 inotropic support

Fairly stable with 2 inotropic support

Fairly stable with 2-4 inotropic support + dysrhythmia

Guarded

Open chest due to hemodynamic stability Vital signs: upon arrival at SICU

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat

Latest Clinical Findings: Urine Output: _____ CTT output: ______ Skin: __pale __pink __jaundice __cyanotic Pupils (size/reactivity): ________________ Conjunctiva (pale/pink): _______________ Chest Expansion: ____________________ Lungs (breath sounds): ________________ Heart ______________________________ ___________________________________ ___________________________________ Abdomen: __________________________

Liver edge: _______________________ Peripheral and Central pulses: __________ Extremities: Warm / cold ______________ CRT: ___ <2sec ___> 2 sec Neuro exam

Check for arrhythmias (Drugs when needed): Antiarrhythmic Drugs

_______________________________________

Check for Chest tube drainage/Bleeding: less than 10% of total blood volume (TBV)/hr >10% TBV /hr With decrease in BP > 10 mmHg/hr

Check for signs of cardiac tamponade Hypotension BP (< 5% for age) ____________ Low cardiac output with need for increased

inotropic requirement Narrow pulse pressure Sudden cessation of mediastinal bleeding Pulsus Paradoxus 2D echocardiogram findings _____________

Check parameters for re-exploration : Total Blood Volume for age: wt : ___ x 80 = ____ cc Any of the following: > 15% of TBV for weight per hour 10-20cc/kg/hr More than 10cc/kg/hr for successive 3 hours More than 30 cc/kg bleeding at any one time Hypotension _________________________

Diet / Nutrition : Maintain on NPO Hgt (Refer for Hgt <50 mg/dl or > 150 mg/dl)

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Activity and Hygiene Promote Safety (follow safety guidelines) Assist in position of airway

Provide Psychological Support to the Family:

Explain to the parents/guardian:

Intraoperative and postoperative findings

Course at SURGICAL ICU

Other complications

Plan of Care PARENTS/GUARDIAN UNDERSTOOD AND

VERBALIZED THE TOF POST-OPERATIVE CARE PLAN

( ) Yes ( ) No

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NURSING ASSESSMENT: Braden Risk Score: _____________ General Pain Assessment: _____________ NIPS – FACES: _____________ Fall Risk Score: _____________ Post-op Wound Assessment

____________

INTERPRETATION:

OUTCOME GOALS: Vital signs stable No cardiac tamponade /

bleeding Post-operative care and plan

explained to parents and/or guardian

( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N

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ACTIVATED BY : ACKNOWLEDGED BY: ____________________________ Signature over Printed Name TCVS CONSULTANT / FELLOW-ON-DUTY Date/Time________________

____________________________ Signature over Printed Name ANESTHESIA CONSULTANT / FELLOW-ON-DUTY Date/Time__________________

________________________ Signature over Printed Name PEDIATRIC CARDIOLOGY CONSULTANT / FELLOW Date/Time ______________

_______________________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (AM shift) Date / Time_____________________ _______________________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (PM shift) Date /Time_______________________








SEX: ( ) M ( ) F



DAY 3: OR DAY Pathway Activated: Date:______Time:_______Pathway Terminated: Date:_______Time:_______ (Day 3-3) 8

7 – 12 HOURS POST SURGERY CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE

Clinical Signs/Symptoms:

Vital signs

BP= HR = RR =

Temp = Ht = Wt =

BSA = BMI=

O2 sat= CVP=

Urine Output: __________ CTT output: ____________ Physical Examination Skin: __pale__pink__ jaundice__cyanotic Pupils :(size/reactive) ________________ Conjunctiva:__pale__pink__suffused Chest Expansion:___________________ Lungs (breath sounds)_______________ Heart (murmurs)___________________ Abdomen_________________________

Liver edge_______________________ Pulses: Peripheral __________________ Central______________________ Extremities: ____Warm ____ Cold CRT: ___ <2sec ___> 2 sec Neuro exam:

Monitor vital signs and review of systems every 15 minutes for the first two hours then every 30 minutes for 2 hours then hourly thereafter.


Hook to Capnograph

Place on temperature regulatory device if indicated

Maintain UO: ________ cc/hr CVP: _________ CTT (< 2cc/kg/hr): ______________________

Laboratory Tests (indicate time): ABG, lactate and Serum electrolytes (Na, K, Calcium,

Magnesium): ______________________________ CBC with APC:_____________________________ PT, PTT:__________________________________ 2D Echocardiogram: _______________________

OXYGEN Therapy: Ventilatory Support :

FiO2 RR

TV / PIP PEEP

Total Fluid Requirement : 750 -1000 cc/ BSA (1.2 – 2 cc/kg/hr) ____cc/day

Cardiac Supports (dose:concentration) Dopamine: (____:_________)__________cc/hr NTG: (____:_________)__________cc/hr Milrinone: (____:_________)__________cc/hr Others:

________ (____:_________)___________cc/hr ________ (____:_________)___________cc/hr

A – Line: __________________________cc/hr CVP Line: __________________________cc/hr Medication Line: _______________________cc/hr

TOTAL Rate: __________________________cc/hr

On-going blood products: 1. _______________________________________________________ 2. _______________________________________________________

Medications Calcium gluconate:__________________________ H2-blocker/Proton Pump Inhibitor: ____________ _____________________________________________ Vancomycin:_______________________________ _____________________________________________ Sedative:__________________________________ Others: ___________________________________ _____________________________________________

Check for arrhythmias (Drugs when needed): Antiarrhythmic drugs:

_________________________________________


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DATE OF BIRTH _______________ MM/DD/ YYYY

SEX: ( ) M ( ) F



DAY 3: OR DAY Date: ___________________________________Time:____________ (Day 3-4) 9

7 – 12 HOURS POST SURGERY CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE

Check for signs of cardiac tamponade Hypotension BP (< 5% for age) ______________ Low cardiac output with need for increased

inotropic requirement Narrow pulse pressure Sudden cessation of mediastinal bleeding Pulsus Paradoxus 2D echocardiogram findings _______________

Check parameters for re-exploration : Total Blood Volume for age: wt : ___ x 80 = _____ cc Any of the following: > 15% of TBV for weight per hour 10-20cc/kg/hr More than 10cc/kg/hr for successive 3 hours More than 30 cc/kg bleeding at any one time Hypotension _________________________

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Other complications

Plan of Care PARENTS/GUARDIAN UNDERSTOOD AND

VERBALIZED THE TOF POST-OPERATIVE CARE PLAN

( ) Yes ( ) No


OUTCOME GOALS: Vital signs stable No cardiac tamponade/bleeding Post-operative care and plan


( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N

A___B___C___D__ A___B___C___D__ A___B___C___D__

ACTIVATED BY: _______________________________ Signature over Printed Name PEDIATRIC CARDIOLOGY CONSULTANT / FELLOW-ON-DUTY Date__________Time________

ACKNOWLEDGED BY: _______________________________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (AM shift) Date / Time____________________

_____________________________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (PM shift) Date / Time____________________

VARIANCE CODES










9. Other reasons







SEX: ( ) M ( ) F



DAY 3: OR DAY Pathway Activated: Date:_______Time:_______Pathway Terminated: Date:_______Time:_____(Day 3-5) 10

12 - 18 HOURS POST SURGERY CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE


Vital signs:

BP= HR = RR =

Temp = Ht = Wt =

BSA = BMI=

O2 sat= CVP=



Monitor vital signs and review of systems every 15 minutes for the first two hours then every 30 minutes for 2 hours then hourly thereafter.


Hook to Capnograph


Monitor UO: _____ cc/hr CVP: ________ CTT (< 2cc/kg/hr): ____________________

Laboratory Tests (indicate time): ABG, lactate and Serum electrolytes (Na, K, Calcium,

Magnesium) ____________________________ CBC with APC __________________________ PT, PTT ________________________________ 2D Echocardiogram _____________________

Oxygen Therapy: If Extubated:

Room air Nasal Cannula at _______LPM Face Mask at __________LPM

If Intubated: (see Pulmonary Referral Notes) Ventilatory Support :

FiO2 RR

TV / PIP PEEP

Total Fluid Requirement : 750 -1000 cc/ BSA (1.2 – 2 cc/kg/hr) ______cc/day Cardiac Supports (dose:concentration) Dopamine: (____:_________)_____________cc/hr NTG: (____:_________)_____________cc/hr Milrinone: (____:_________)_____________cc/hr Others:

________(____:_________)______________cc/hr ________(____:_________)_____________ cc/hr

A – Line: ___________________________cc/hr CVP Line: ___________________________cc/hr Medication Line: ________________________cc/hr TOTAL Rate: __________________________cc/hr

On-going blood products: 1. ___________________________________________ 2. ___________________________________________ Medications Calcium gluconate:____________________________ H2-blocker/Proton Pump inhibitor:_______________

___________________________________________ Vancomycin:_________________________________

___________________________________________ Sedatives:___________________________________ Others: _____________________________________ _____________________________________

Check for arrhythmias (Drugs when needed): Antiarrhythmic drugs: _________________________

___________________________________________

A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___

A___B___C___D___ A___B___C___D___



SEX: ( ) M ( ) F



DAY 3: OR DAY Date: ___________________________________Time:____________ (Day 3-6) 11



Check for signs of cardiac tamponade: Hypotension BP (< 5% for age) ______________ Low cardiac output with need for increased inotropic

requirement Narrow pulse pressure Sudden cessation of mediastinal bleeding Pulsus Paradoxus 2D echocardiogram findings _______________

Check parameters for re-exploration : Total Blood Volume for age: wt : ____ x 80 = _____ cc Any of the following: > 15% of TBV for weight per hour 10-20cc/kg/hr More than 10cc/kg/hr for successive 3 hours More than 30 cc/kg bleeding at any one time Hypotension _________________________


A___B___C___D__ A___B___C___D__ A___B___C___D__

A___B___C___D__


A___B___C___D__


A___B___C___D__






Other complications

Plan of Care PARENTS/GUARDIAN UNDERSTOOD AND VERBALIZED

THE TOF POST-OPERATIVE CARE PLAN ( ) Yes ( ) No

A___B___C___D__ A___B___C___D__ A___B___C___D__ A___B___C___D__ A___B___C___D__ A___B___C___D__ A___B___C___D__

OUTCOME GOALS: Vital signs stable No cardiac tamponade / bleeding Post-operative care and plan


( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N

A___B___C___D__ A___B___C___D__ A___B___C___D__

ACTIVATED BY: ACKNOWLEDGED BY: _____________________________ Signature over Printed Name PEDIATRIC CARDIOLOGY CONSULTANT/ FELLOW-ON-DUTY Date______Time______

_______________________________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (AM shift) Date / Time____________________

_____________________________________ Signature over Printed Name BEDSIDE NURSE-ON-DUTY (PM shift) Date / Time____________________

VARIANCE CODES

A. PATIENT / FAMILY B. HEATH PROVIDER C. PHC SYSTEMS D. OUTSIDE PHC 1. Patient’s medical condition 1.Medical order 1. Results / Data availability 1. Condition / Transportation








9. Other reasons







SEX: ( ) M ( ) F



DAY 3: OR DAY Pathway Activated: Date:_______Time:_______ Pathway Terminated: Date:_____Time:____(Day 3-7) 12



Vital signs:

BP= HR = RR =

Temp = Ht = Wt =

BSA = BMI=

O2 sat= CVP=



Monitor vital signs and review of systems every 15 minutes for the first two hours then every 30 minutes for 2 hours then hourly thereafter


Hook to Capnograph


Monitor UO: _____ cc/hr CVP: ___________ CTT (< 2cc/kg/hr): ____________________

Laboratory Tests (indicate time): ABG, lactate and Serum electrolytes (Na, K,

Calcium, Magnesium) _____________________ CBC with APC ___________________________ PT, PTT ________________________________ 2D Echocardiogram ______________________



If Intubated (see Pulmonary Referral Notes): Ventilatory Support :

FiO2 RR

TV / PIP PEEP

Total Fluid Requirement : 750 -1000 cc/ BSA (1.2 – 2 cc/kg/hr) ______cc/day

Cardiac Supports (dose:concentration) Dopamine: (____:_________)____________cc/hr NTG: (____:_________)____________cc/hr Milrinone: (____:_________)____________cc/hr Others: _________(___:_________)____________cc/hr _________(___:_________)_____________cc/hr

A – Line: ____________________________cc/hr CVP Line: ____________________________cc/hr Medication Line: ______________________cc/hr

TOTAL Rate: ________________________cc/hr

On-going blood products: 1. _________________________________________ 2. _______________________________________________________

Medications Calcium gluconate:________________________ H2-blocker/Proton Pump Inhibitor____________

________________________________________ Vancomycin:_______________________________

_________________________________________ Sedative:__________________________________ ____________________________________________ Others:

______________________________________

A___B___C___D___



A___B___C___D___ A___B___C___D___ A___B___C___D___

A___B___C___D___ A___B___C___D___

A___B___C___D___

A___B___C___D___ A___B___C___D___ A___B___C___D___


A___B___C___D___ A___B___C___D___

A___B___C___D___ A___B___C___D___

A___B___C___D___

A___B___C___D___

A___B___C___D___



SEX: ( ) M ( ) F



DAY 3: OR DAY Date: _________________________________Time:____________ (Day 3-8) 13


Check for arrhythmias (Drugs when needed): Antiarrhythmic Drugs: ______________________

__________________________________________

Check for Chest tube drainage/Bleeding: Total Blood Volume for age: wt : ____ x 80 = _____ cc less than 10% of total blood volume (TBV)/hr >10% TBV /hr With decrease in BP > 10 mmHg/hr

Check for signs of cardiac tamponade Hypotension BP (< 5% for age) ______________ Low cardiac output with need for increased inotropic

requirement Narrow pulse pressure Sudden cessation of mediastinal bleeding Pulsus Paradoxus 2D echocardiogram findings _______________

Check parameters for re-exploration : Total Blood Volume for age: wt : ____ x 80 cc /kg _____ Any of the following: > 15% of TBV for weight per hour 10-20cc/kg/hr More than 10cc/kg/hr for successive 3 hours More than 30 cc/kg bleeding at any one time Hypotension _________________________


A___B___C___D__ A___B___C___D__

A___B___C___D__ A___B___C___D__ A___B___C___D__

A___B___C___D__


A___B___C___D__


A___B___C___D__






Other complications

Plan of Care PARENTS/GUARDIAN UNDERSTOOD AND VERBALIZED

THE TOF POST-OPERATIVE CARE PLAN ( ) Yes ( ) No

A___B___C___D__ A___B___C___D__ A___B___C___D__ A___B___C___D__ A___B___C___D__ A___B___C___D__ A___B___C___D_

OUTCOME GOALS: Vital signs stable No cardiac tamponade/bleeding Post-operative care and plan


( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N

A___B___C___D__ A___B___C___D__

A___B___C___D__

ACTIVATED BY: ____________________________ Signature over Printed Name PEDIATRIC CARDIOLOGY CONSULTANT / FELLOW-ON-DUTY Date_______________Time________

ACKNOWLEDGED BY: _______________________________________ Signature over Printed Name Bedside Nurse-On-Duty (AM shift) Date / Time__________________

___________________________________ Signature over Printed Name Bedside Nurse-On-Duty (PM shift) Date / Time__________________








SEX: ( ) M ( ) F



DAY 4: Post op Day 1: Pathway Activated: Date:_____Time:_____ Pathway Terminated: Date:_____Time:_____(Day 4-1 ) 14

FIRST 8 HOURS CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE


Vital signs:

BP= HR = RR =

Temp = Ht = Wt =

BSA = BMI=

O2 sat= CVP=

Urine Output: __________ CTT output: ____________ Physical Examination Skin: __pale__pink__ jaundice__cyanotic Pupils :(size/reactive) _______________ Conjunctiva:__pale__pink__suffused Chest Expansion:___________________ Lungs (breath sounds)______________ Heart (murmurs)___________________ Abdomen_________________________

Liver Edge _____________________ Pulses: Peripheral _______________________ Central__________________________ Extremities: ____Warm ____ Cold CRT: ___ <2sec ___> 2 sec Neuro exam:

Monitor vital signs, input and output.

Laboratory Tests: ABG, lactate and Serum electrolytes (Na, K, Ca, Mg) CBC with APC PT, PTT CXR




FiO2 RR

TV / PIP PEEP

Check : Parameters for weaning from Mechanical Ventilation/Extubation: Awake with stimulation Adequate reversal of anaesthesia Core temperature > 35.5 C Hemodynamic stability ABG : at FiO2 50%, pO2 > 75 torr ABG pCO2 <45 pH 7.35-7.50 Tolerates further weaning to FiO2 30% at SIMV

or Spontaneous mode With O2 saturation > 95% , no hypotension

CXRay not congested No increased effort of breathing

Total Fluid Requirement (TFR) : Increase to 1000-1500 cc/ BSA) ______ cc/day

Cardiac Supports (dose:concentration) Dopamine: (____:_________)_________cc/hr NTG: (____:_________)_________cc/hr Milrinone: (____:_________)_________cc/hr Others:

________(____:_________)__________cc/hr ________(____:_________)_________cc/hr

A – Line: ______________________cc/hr CVP Line: ______________________cc/hr Medication Line: ___________________cc/hr

TOTAL Rate: ______________________cc/hr

Parameters for weaning from IV Inotropic support

BP >90 mmHg at least 12 hours Urine output > 1cc/kg/hr Warm extremities with CRT < 2 sec If with inotropic support > 48 hours or after

D3, specify reason ___________________________

A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D__ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___ A___B___C___D___



SEX: ( ) M ( ) F

PHILHEALTH NUMBER ________________________ ( )Father ( )Mother


DAY 4 Post op Day 1: Date: ____________________________Time:___________ (Day 4-2) 15

FIRST 8 HOURS CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE

Findings prior transfer to PICU Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat



Medications: Calcium gluconate:_________________________ H2-blocker/Proton Pump Inhibitor: ___________ Others: __________________________________

__________________________________

Check Nutrition NPO while intubated. Monitor Hgt. Start soft diet 4 hours after extubation Progress to regular diet for age

Check parameters for chest tube removal Chest tube drainage <100 ml x 8h If CT removal after day 3

Specify reason : ________________________________

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__

Criteria for TRANS-OUT FROM SURGICAL ICU to PICU :

No risk for cardiac tamponade No indication for re-exploration of mediastinum or

re-operation If the patient is unable to transfer after day 2,

specify reason : ________________________________

Check Physical Activity Complete Bed rest or as ordered Elevate head of bed to at least 30 degrees Patient demonstrates a daily increase in activity

level

A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

Provide Psychological support to family :

Explain to the patient and family

Risks/ Complications involved

Duration of SICU stay

Duration of PICU stay

Transfer to room and duration of hospital stay

Explanation of prognosis

Importance of Ambulation and increased activity

Plan of Care

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

OUTCOME GOALS:

Stable Vital Signs

Transfer to PICU

( ) Y ( ) N ( ) Y ( ) N

A__ B__ C__ D__ A__ B__ C__ D__

DISCHARGE PLANNING Ready For transfer to PICU Defer Transfer

A__ B__ C__ D__ A__ B__ C__ D__

ACTIVATED BY:

Signature over Printed Name ATTENDING PHYSICIAN/ FELLOW-ON-DUTY Date/Time_______________

ACKNOWLEDGED BY:

Signature over Printed Name NURSE-IN-CHARGE (AM Shift) Date/Time______________

__________________________________ Signature over Printed Name NURSE-IN-CHARGE (PM Shift) Date/Time__________________

VARIANCE CODES









9. Other reasons

( ) Y ( ) N ( ) Y ( ) N







SEX: ( ) M ( ) F



DAY 4 Post op Day 1: Pathway Activated: Date:_____Time:_____ Pathway Terminated: Date:_____Time:_____ (Day 4-3) 16

8 - 16 HOURS CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat


Liver edge: _______________________ Peripheral and Central pulses: __________ Extremities: Warm / cold ______________ CRT: ___ <2sec ___> 2 sec Neuro exam Latest Laboratory findings: CBC Na_____ K _____ Ca ______ Mg _____ ABG: pH_____ pCO2______ pO2______ HCO3_____ BE______ PTT________ PT _____ CXR:________________

Monitor Vital signs, input, output

Request for the following diagnostics: ABG, lactate and Serum electrolyte CBC PT, PTT CXR




FiO2 RR

TV / PIP PEEP

Check : Parameters for weaning from Mechanical Ventilation/Extubation(see Pulmonologist Referral form for Pulmo orders):

Awake with stimulation Adequate reversal of anaesthesia

Core temperature > 35.5 C Hemodynamic stability ABG : at FiO2 50%, pO2 > 75 torr ABG pCO2 <45 pH 7.35-7.50 Tolerates further weaning to FiO2 30% at SIMV or

Spontaneous mode With O2 saturation > 95% , no hypotension

CXRay not congested No increase effort of breathing

Total Fluid Requirement Increase to 1000 -1500 cc/ BSA__________ cc/day

IVF Rate : ___________________________cc/hr

Cardiac Supports (dose:concentration) Dopamine: (____:_______)__________cc/hr NTG: (____:_______)__________cc/hr Milrinone: (____:_______)__________cc/hr Others:

________(____:_______)___________cc/hr ________(____:_______)___________cc/hr

A – Line: ________________________cc/hr CVP Line: ________________________cc/hr Medication Line: ____________________cc/hr

TOTAL Rate: ___________________cc/hr

Parameters for weaning from IV Inotropic support BP >90 mmHg at least 12 hours Urine output > 1cc/kg/hr Warm extremities with CRT < 2 sec If with inotropic support > 48 hours or after D3,

specify reason ___________________________

A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__



NURSING ASSESSMENT: Braden Risk Score: _____________ General Pain Assessment: ______________ NIPS – FACES: ______________ Fall Risk Score: ______________ Post-op Wound Assessment ______________

INTERPRETATION:



SEX: ( ) M ( ) F



DAY 4 Post op Day 1: Date: ___________________________________Time:____________ (Day 4-4) 17

8 - 16 HOURS

CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Findings prior transfer to PICU Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat

Latest Clinical Findings: Urine Output: _____ CTT output: ______ Skin: __pale __pink __jaundice __cyanotic Pupils (size/reactivity): _______________ Conjunctiva (pale/pink): ______________ Chest Expansion: ____________________ Lungs (breath sounds): _______________ Heart _____________________________ __________________________________ __________________________________ Abdomen: _________________________

Liver edge: _______________________ Peripheral and Central pulses: _________ Extremities: Warm / cold _____________ CRT: ___ <2sec ___> 2 sec Neuro exam

Medications

Calcium gluconate:_________________________

H2-blocker/Proton Pump Inhibitor:____________ _________________________________________

Others: __________________________________

________________________________________

________________________________________


Check parameters for chest tube removal Chest tube drainage <100 ml x 8h If CT removal after day 3

Specify reason :__________________________

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

Criteria for TRANS-OUT FROM SICU to PICU : No risk for cardiac tamponade Without indication for re-exploration of

mediastinum or re-operation If the patient is unable to transfer after day 2,

specify reason : _________________________


level

A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__









Plan of Care


A__ B__ C__ D__ A__ B__ C__ D__

OUTCOME GOALS:

Stable Vital Signs

Transfer to PICU

Transfer to Regular Room

( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

DISCHARGE PLANNING Ready For transfer to PICU/Regular Room

A__ B__ C__ D__

ACTIVATED BY:

Signature over Printed Name ATTENDING PHYSICIAN/ FELLOW-ON-DUTY Date/Time_____________

ACKNOWLEDGED BY:

Signature over Printed Name NURSE-IN-CHARGE (AM Shift) Date/Time_______________

__________________________________ Signature over Printed Name NURSE-IN-CHARGE (PM Shift) Date/Time_______________

VARIANCE CODES A. PATIENT / FAMILY B. HEATH PROVIDER C. PHC SYSTEMS D. OUTSIDE PHC









9. Other reasons







SEX: ( ) M ( ) F



DAY 4 Post op Day 1: Pathway Activated: Date: ______Time:_____ Pathway Terminated: Date:_____Time:____ (Day 4-5) 18

16 – 24 HOURS CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat




Request for the following diagnostics: ABG, lactate and Serum electrolyte CBC PT, PTT CXR

Oxygen Therapy: If Extubated: Room air Nasal Cannula at _______LPM Face Mask at __________LPM


FiO2 RR

TV / PIP PEEP

Check : Parameters for weaning from Mechanical Ventilation/Extubation (see

Pulmonologist Referral Form for Pulmo orders): Awake with stimulation Adequate reversal of anaesthesia Core temperature > 35.5 C Hemodynamic stability ABG : at FiO2 50%, pO2 > 75 torr ABG pCO2 <45 pH 7.35-7.50 Tolerates further weaning to FiO2 30% at SIMV or

Spontaneous mode With O2 saturation > 95% , no hypotension

CXRay not congested No increase effort of breathing

Total Fluid Requirement Increase to 1000 -1500 cc/ BSA _________ cc/day

IVF Rate : __________________________cc/hr

Cardiac Supports (dose:concentration) Dopamine: (____:_______)____________cc/hr NTG: (____:_______)____________cc/hr Milrinone: (____:_______)____________cc/hr Others:

__________(____:_______)____________cc/hr _________(____:_______)_____________cc/hr

A – Line:____________________________cc/hr CVP Line: __________________________cc/hr Medication Line: ___________________cc/hr

TOTAL Rate: _______________________cc/hr

Parameters for weaning from IV Inotropic support BP >90 mmHg at least 12 hours Urine output > 1cc/kg/hr Warm extremities with CRT < 2 sec If with inotropic support > 48 hours or after D3,

specify reason ___________________________

A__ B__ C__ D__


A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__



NURSING ASSESSMENT: Braden Risk Score: _____________ General Pain Assessment: _____________ NIPS – FACES: ____________ Fall Risk Score: ____________ Post-op Wound Assessment _________

INTERPRETATION:



SEX: ( ) M ( ) F



DAY 4 Post op Day 1: Date: ___________________________________Time:____________ (Day 4-5) 19

16 – 24 HOURS PHYSICIAN’S NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Findings prior transfer to PICU/Regular Room Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat



Medications Calcium gluconate:________________________ H2-blocker/Proton Pump Inhibitor:___________

________________________________________ Others: _________________________________ ________________________________________ ________________________________________


CHECK PARAMETERS FOR CHEST TUBE REMOVAL Chest tube drainage <100 ml x 8h If CT cannot be removed after day 3 post op

Specify reason :________________________

A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__

A__ B__ C__ D__

Criteria for TRANS-OUT FROM SURGICAL ICU to PICU :

No risk for cardiac tamponade No indication for re-exploration of mediastinum or

re-operation If the patient is unable to transfer after day

2 post-op, specify reason : _________________ _______________________________________

A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__

Check Physical Activity Complete Bed rest or as ordered Elevate head of bed to at least 30 degrees Patient demonstrates a daily increase in activity level

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

Provide Psychological support to family.








Plan of Care


OUTCOME GOALS:

Stable Vital Signs

Transfer to PICU


( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

DISCHARGE PLANNING Ready For transfer to PICU/Regular Room

A__ B__ C__ D__

ACTIVATED BY:

Signature over Printed Name ATTENDING PHYSICIAN/ FELLOW-ON-DUTY Date/Time______________

ACKNOWLEDGED BY:

Signature over Printed Name NURSE-IN-CHARGE (AM Shift) Date/Time________________

__________________________________ Signature over Printed Name NURSE-IN-CHARGE (PM Shift) Date/Time_______________

VARIANCE CODES









9. Other reasons







SEX: ( ) M ( ) F



DAY 5 Post op Day 2: Pathway Activated: Date:________Time:_______Pathway Terminated: Date:________Time:________ (Day5- 1) 20


BP HR RR

Temp Ht Wt

BSA BMI

O2 sat




Request for the following diagnostics: ABG, lactate and Serum electrolytes CBC CXR




FiO2 RR

TV / PIP PEEP

Check : Parameters for weaning from Mechanical Ventilation/Extubation/O2 support (See Pulmonologist Referral form for Pulmo orders)

Awake with stimulation Adequate reversal of anaesthesia Core temperature > 35.5 C Hemodynamic stability ABG : at FiO2 50%, pO2 > 75 torr ABG pCO2 <45 pH 7.35-7.50 Tolerates further weaning to FiO2 30% at SIMV

or Spontaneous mode With O2 saturation > 95% , no hypotension

CXRay not congested No increase work of breathing

Total Fluid Requirement Increase to 1000 -1500 cc/ BSA__________cc/day

IVF Rate : __________________________cc/hr

Cardiac Supports (dose:concentration) Dopamine: (____:_______)__________cc/hr NTG: (____:_______)__________cc/hr Milrinone: (____:_______)__________cc/hr Others: ________(____:_______)__________cc/hr ________(____:_______)__________cc/hr

A – Line: ________________________cc/hr CVP Line: ________________________cc/hr Medication Line: __________________cc/hr

TOTAL Rate: ______________________cc/hr

Parameters for weaning from IV Inotropic support

BP >90 mmHg at least 12 hours Urine output > 1cc/kg/hr Warm extremities with CRT < 2 sec If with inotropic support > 48 hours or after D3,

specify reason ___________________________

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

NURSING ASSESSMENT: Braden Risk Score: ____________ General Pain Assessment: ____________ NIPS – FACES: ____________ Fall Risk Score: ____________ Post-op Wound Assessment ___________

INTERPRETATION:



SEX: ( ) M ( ) F



DAY 5 Post op Day 2: Date: ___________________________________Time:____________ (Day 5-2) 21 CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Findings prior transfer to PICU Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat


Liver edge: _______________________ Peripheral and Central pulses: __________ Extremities: Warm / cold ______________ CRT: ___ <2sec ___> 2 sec Neuro exam:

Medications Calcium Gluconate:_______________________ H2-Blocker/Proton Pump Inhibitor:___________ Others: _________________________________ _______________________________________ _______________________________________

Check Nutrition NPO while intubated. Monitor Hgt Start soft diet 4 hours after extubation Progress to regular diet for age

Check parameters for chest tube removal Chest tube drainage <100 ml x 8h If CT removal after day 3 Specify reason : _____________________________


A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__

Criteria for TRANS-OUT FROM SICU to PICU/ Regular Room :

Stable vital signs > 24 hours after extubation No risk of reperfusion syndrome No significant congestion No cardiac supports Wean supports to at least 5 ug/kg/min Can ambulate Good appetite and tolerates feeding If the patient is unable to transfer after day 2

post-op, specify reason ____________________


level

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__


Explain to the patient and family Risks/ Complications involved Duration of SICU stay Duration of PICU stay Transfer to room and duration of hospital stay Explanation of prognosis Importance of Ambulation and increased activity Plan of Care


OUTCOME GOALS:

Stable Vital Signs

Transfer to PICU


( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

DISCHARGE PLANNING

Ready For transfer to PICU/Regular Room

A__ B__ C__ D__

ACTIVATED BY:


ACKNOWLEDGED BY:


__________________________________ Signature over Printed Name NURSE-IN-CHARGE (PM Shift) Date/Time________________

VARIANCE CODES










9. Other reasons







SEX: ( ) M ( ) F



DAY 6 Post op Day 3: Pathway Activated: Date:_____Time:_____ Pathway Terminated: Date:_____Time:_____(Day 6-1) 22


BP HR RR

Temp Ht Wt

BSA BMI

O2 sat



Monitor vital signs, input, output

Laboratory Exams: CBC with APC Serum Na, K, Calcium CXR




FiO2 RR

TV / PIP PEEP

Parameters for Extubation in Prolonged Ventilation (after 72 hours)(See Pulmonologist

referral Form for Pulmo Orders) Comfortable breathing pattern without

diaphoresis, agitation/ anxiety, RR < 30/min Adequate mental status to protect airway, initiate

cough Hemodynamic stability with no vasoactive drugs Satisfactory ABG Reason if the patient cannot be extubated after

day 5 ___________________________ Check parameters for TRANS-OUT FROM PICU TO

REGULAR ROOM: Stable vital signs > 24 hours after extubation No risk of reperfusion syndrome No significant congestion No cardiac supports Wean supports to at least 5 ug/kg Can ambulate Good appetite and tolerates feeding

If the patient is unable to transfer after day 2 post-op, specify reason ____________________

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

NURSING ASSESSMENT: Braden Risk Score: ______________ General Pain Assessment: ______________ NIPS – FACES: ______________ Fall Risk Score: ______________ Post-op Wound Assessment ____________

INTERPRETATION:

Total Fluid Requirement : After day 3 Postop : Adjust accordingly to 1500-

1700 cc/BSA and ad libitum with priority for oral fluids: _____________________cc/day

IVF Rate : __________________________cc/hr

Cardiac Supports (dose:concentration) Dopamine: (____:_______)_____________cc/hr NTG: (____:_______)_____________cc/hr Milrinone: (____:_______)_____________cc/hr Others: ________(____:_______)_____________cc/hr ________(____:_______)_____________cc/hr A – Line: ___________________________cc/hr CVP Line: ___________________________cc/hr Medication Line: _____________________cc/hr

TOTAL Rate: _____________________cc/hr

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__



SEX: ( ) M ( ) F



DAY 6 Post op Day 3: Date: ___________________________________Time:____________ (Day 6-2) 23 CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Findings prior transfer to Room Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat

Latest Clinical Findings: Urine Output: _____ CTT output: _____ Skin: __pale __pink __jaundice __cyanotic Pupils (size/reactivity): _______________ Conjunctiva (pale/pink): ______________ Chest Expansion: ____________________ Lungs (breath sounds): _______________ Heart _____________________________ __________________________________ __________________________________ Abdomen: _________________________

Liver edge: _______________________ Peripheral and Central pulses: _________ Extremities: Warm / cold _____________ CRT: ___ <2sec ___> 2 sec Neuro exam

Continue weaning from IV Inotropic supports and discontinue if the patient demonstrate the following:

BP > 90 mmHg for at least 12 hours

Urine output > 1cc/kg/hr

Warm extremities with CRT < 2sec

If with inotropic support > 48 hrs

or after day 5, specify reason : ______________________________________

Shift as necessary to oral medications : Digoxin : _________________________________ Diuretic : _________________________________ Vasodilator : ______________________________ Antibiotic: ________________________________ Others : __________________________________ _________________________________________

Check Nutrition Start Feeding Regular diet for age

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

Encourage Physical Activity Complete Bed rest or as ordered Elevate head of bed to at least 30 degrees Patient demonstrates a daily increase in activity level Play therapy appropriate for age and post op

condition Refer to PEDIA Cardiac Rehab (Pedia Care) after day

3 post op _________________________________ _________________________________________







Plan of Care


OUTCOME GOALS: Stable Vital signs Transfer to regular room Referred to Pedia Care Rehab

( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

DISCHARGE PLANNING Transfer to regular Pediatric Ward

( ) Y ( ) N

A__ B__ C__ D__

ACTIVATED BY:

Signature over Printed Name ATTENDING PHYSICIAN/ FELLOW-ON-DUTY Date/Time__________________

ACKNOWLEDGED BY:

Signature over Printed Name NURSE-IN-CHARGE (AM Shift) Date/Time_______________-

_________________________________ Signature over Printed Name NURSE-IN-CHARGE (PM Shift) Date/Time_______________

VARIANCE CODE A. PATIENT / FAMILY B. HEATH PROVIDER C. PHC SYSTEMS D. OUTSIDE PHC









9. Other reasons







SEX: ( ) M ( ) F



DAY 7 Post op Day 4: Pathway Activated: Date:______Time:______ Pathway Terminated: Date:______Time:______ (Day 7-1) 24 CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Clinical Findings prior transfer to Room Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat



Monitor vital signs, input, output

Lab / Ancillary Request Chest X-ray 2D echocardiogram

Oxygen Therapy: Room air Nasal Cannula at _______LPM Total Fluid Requirement :

After day 4 Postop : Adjust accordingly to 1500- 1700 cc/BSA and ad libitum with priority for oral fluids

Total Fluid intake: ____________________cc/day

Drugs and Inotropes (dose:concentration): Dopamine: (_____:________)____________cc/hr Milrinone : (_____:________)____________cc/hr Others: _____________________________cc/hr

______________________________cc/hr

Continue weaning from IV Inotropic support and discontinue if the patient demonstrates the following :

BP > 90 mmHg for at least 12 hours

Urine output > 1cc/kg/hr

Warm extremities with CRT < 2sec

If with inotropic support > 48 hrs post op or after day 5, specify reason :

____________________________________

Shift/continue as necessary to oral medications : Digoxin : _________________________________ Diuretic : _________________________________ Vasodilator : ______________________________ Antibiotic: ________________________________ Others : __________________________________

________________________________________ _________________________________________ _________________________________________

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

NURSING ASSESSMENT: Braden Risk Score: ______________ General Pain Assessment: ______________ NIPS – FACES: ______________ Fall Risk Score: ______________ Post-op Wound Assessment _____________

INTERPRETATION:


A__ B__ C__ D__ A__ B__ C__ D__



SEX: ( ) M ( ) F



DAY 7 Post op Day 4: Date: ___________________________________Time:___________ (Day 7-2) 25 CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Findings prior transfer to Room Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat



Check parameters for TRANS-OUT FROM PICU TO REGULAR ROOM:

Stable vital signs > 24 hours after extubation Weaned supports to at least Minimal of 1 inotrope Tolerates feeding

If the patient cannot be transferred to regular room after day 6, specify reason : ______________________________________ ______________________________________ ______________________________________ ______________________________________

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__


Encourage Physical Activity Complete Bed rest or as ordered Elevate head of bed to at least 30 degrees Patient demonstrates a daily increase in activity

level Play therapy appropriate for age and post op

condition Refer to PEDIA Cardiac Rehab (Pedia Care)

after day 3 ______________________________________

______________________________________

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__

A__ B__ C__ D__



Duration of hospital stay



Plan of Care


OUTCOME GOALS: Stable Vital signs Transfer to regular room Referred to Pedia Care Rehab

( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

DISCHARGE PLANNING

Transfer to regular Pediatric Ward

( ) Y ( ) N

A__ B__ C__ D__

ACTIVATED BY:

Signature over Printed Name ATTENDING PHYSICIAN/ FELLOW-ON-DUTY Date/Time___________

ACKNOWLEDGED BY:


__________________________________ Signature over Printed Name NURSE-IN-CHARGE (PM Shift) Date/Time________________

VARIANCE CODES A. PATIENT / FAMILY B. HEATH PROVIDER C. PHC SYSTEMS D. OUTSIDE PHC









9. Other reasons







SEX: ( ) M ( ) F



DAY 8 Post op Day 5: Pathway Activated: Date:______Time:______ Pathway Terminated: Date:______Time:______ (Day 8-1) 26 CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Clinical Findings prior to discharge Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat



Monitor vital signs

Laboratory Tests Chest X-ray 2D echocardiogram 15L ECG

Check Parameters for Discharge after day 8 Discharge Criteria : Stable vital signs O2saturation of 96% and above Stable co-morbid illness

Total Fluid requirement (TFR / BSA) _________________cc/day

Continue IV: Rate :_______________________cc/hr Specify reason if IV cannot be discontinued: ___________________________________________ ___________________________________________ Limit oral fluids to ______________________________________cc/day Fluids ad libitum

Shift/continue as necessary to oral medications : Digoxin : _______________________________ Diuretic : _______________________________ Vasodilator : ____________________________ Antibiotic: ______________________________ Others:_________________________________


Encourage Physical Activity Patient demonstrates a daily increase in activity

level Pedia Cardiac Rehabilitation Program (Pedia Care) : ________________________________ ________________________________

A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__



A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

NURSING ASSESSMENT: Braden Risk Score: ______________ General Pain Assessment: ______________ NIPS – FACES: ______________ Fall Risk Score: ______________ Post-op Wound Assessment _____________

INTERPRETATION:





Plan of Care

Discharge plans




SEX: ( ) M ( ) F



DAY 8 Post op Day 5: Date: ___________________________________Time:____________ (DAY 8-2) 27 CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE

DISCHARGE PLANNING Facilitate discharge by instructing family regarding

discharge procedures Finalize discharge instructions. Give clear copy of

discharge instructions. Discharge instructions and medications including

prescription given: 1. __________________________________________ 2. __________________________________________ 3. __________________________________________ 4.__________________________________________ 5.__________________________________________

If the patient cannot be discharged after day 9, specify reason :

__________________________________________

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

OPD PLAN OF CARE : Follow-up : When:_________ Where:__________ CXRay: When: ________________ 2D echocardiogram: When: _____________ Cardiac Rehabilitation Plan of Care and OPD Follow-up__________________

ACTIVITY _______________________________ NUTRITION/ DIET :

___________________________________ PARENTS/GUARDIAN UNDERSTOOD, VERBALIZED,

CONSENTED, AND SIGNED THE POST-TOF CORRECTION CARE PLAN

( ) Yes ( ) No

If yes, Request parents to FILL UP and SUBMIT PATIENT SATISFACTION SURVEY


OUTCOME GOALS Stable Vital signs Discharge to Home Submitted the TOF Database Form Home medications given Activity discharge safety give Philhealth form accomplished and

submitted

( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N


DISCHARGE PLANNING

Tentative Date of Discharge: ___________________

A__ B__ C__ D__

ACTIVATED BY:

Signature over Printed Name ATTENDING PHYSICIAN/ FELLOW-ON-DUTY Date/Time______________

ACKNOWLEDGED BY:

Signature over Printed Name NURSE-IN-CHARGE (AM Shift) Date/Time_________________

__________________________________ Signature over Printed Name NURSE-IN-CHARGE (PM Shift) Date/Time_________________

VARIANCE CODE










9. Other reasons







SEX: ( ) M ( ) F



DAY 9 Post op Day 6: Pathway Activated: Date:______Time:______ Pathway Terminated: Date:______Time:______ (Day 9-1) 28 CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Clinical Findings prior to discharge Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat



Monitor vital signs

LaboratoryTests Chest X-ray 2D echocardiogram 15L ECG

Check Parameters for Discharge after day 8 Discharge Criteria : Stable vital signs O2saturation of 95% and above Stable co-morbid illness

Total Fluid requirement Continue IV: Rate : __________________cc/day Specify reason if IV cannot be discontinued ___________________________________________ ___________________________________________ Limit oral fluids to ____________________________________cc/day Fluids ad libitum

Shift as necessary to oral medications : Digoxin : __________________________________ Diuretic : _________________________________ Vasodilator : _______________________________ Antibiotic: _________________________________ Others: ___________________________________

_________________________________________ _________________________________________

Check Nutrition Start Feeding Regular diet for age Encourage Physical Activity Patient demonstrates a daily increase in activity

level Pedia Cardiac Rehabilitation Program (Pedia Care) : ________________________________ ________________________________

A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__

A__ B__ C__ D__


A__ B__ C__ D__ A__ B__ C__ D__

A__ B__ C__ D__ A__ B__ C__ D__

Provide Psychological support to family : Explain to the patient and family



Plan of Care

Discharge plans




SEX: ( ) M ( ) F



DAY 9 Post op Day 6: Date: ___________________________________Time:____________ (Day 9-2) 29 PHYSICIAN’S NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Findings prior to Discharge Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat






prescription given: 1. ________________________________ 2. ________________________________ 3. ________________________________ 4.________________________________ 5.________________________________ If the patient cannot be discharged after day 9, specify

reason : ___________________________ __________________________________

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

OPD PLAN OF CARE : Follow-up : When:_________ Where:__________ CXRay: When: ________________ 2D echocardiogram: When: _____________ Cardiac Rehabilitation Plan of Care and OPD Follow-

up______________________________ ACTIVITY _______________________________ NUTRITION/ DIET :________________________ PARENTS/GUARDIAN UNDERSTOOD, VERBALIZED,


( ) Y ( ) N


NURSING ASSESSMENT: Braden Risk Score: ___________ General Pain Assessment: ___________ NIPS – FACES: ___________ Fall Risk Score: __________ Post-op Wound Assessment ____________

INTERPRETATION:

OUTCOME GOALS Stable Vital signs Discharge to Home Parents accomplished and

submitted Satisfaction Survey Form Philhealth form accomplished and

submitted

( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N


DISCHARGE CHECKLIST

Discharge summary

Patient Satisfactory Survey Form

TOF Data base form

Philhealth Form Submitted

Medication Reconciliation Form (MRF) Accomplished


DISCHARGE PLANNING Date of Discharge: ___________________________

A__ B__ C__ D__

ACTIVATED BY:


ACKNOWLEDGED BY:

Signature over Printed Name NURSE-IN-CHARGE (AM Shift) Date/Time________________

_________________________________ Signature over Printed Name NURSE-IN-CHARGE (PM Shift) Date/Time_______________

VARIANCE CODE










9. Other reasons







SEX: ( ) M ( ) F



DAY 10 Post op Day 7:Pathway Activated: Date:______Time:______Pathway Terminated: Date:______Time:_____ (Day 10-1) 30 CLINICAL NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Clinical Findings prior to discharge Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat



Monitor vital signs

LaboratoryTests Chest X-ray 2D echocardiogram

15L ECG Check Parameters for Discharge after day 8 Discharge Criteria : Stable vital signs O2saturation of 95% and above Stable co-morbid illness

Total Fluid requirement Continue IV Rate : _______________________________cc/day Specify reason if IV cannot be discontinued ___________________________________________ ___________________________________________ Limit oral fluids to ___________________________________________ Fluids ad libitum

Shift as necessary to oral medications : Digoxin : __________________________________ Diuretic : _________________________________ Vasodilator : _______________________________ Antibiotic: _________________________________ Others:____________________________________

_________________________________________

Check Nutrition Start Feeding Regular diet for age Encourage Physical Activity Patient demonstrates a daily increase in activity level Pedia Cardiac Rehabilitation Program (Pedia Care) : ________________________________ ________________________________

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

Provide Psychological support to family : Explain to the patient and family



Plan of Care

Discharge plans




SEX: ( ) M ( ) F

PHILHEALTH NUMBER ______________________________ ( )Father ( )Mother


DAY 10 Post op Day 7: Date: ___________________________________Time:____________ (Day 10-2) 31 PHYSICIAN’S NOTES PHYSICIAN’S ORDERS SIGNATURE VARIANCE Findings prior to Discharge Subjective complaints/symptoms: Vital signs:

BP HR RR

Temp Ht Wt

BSA BMI

O2 sat






prescription given: 1. ________________________________ 2. ________________________________ 3. ________________________________ 4.________________________________ 5.________________________________ If the patient cannot be discharged after day 9, specify

reason : ___________________________

A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__ A__ B__ C__ D__

OPD PLAN OF CARE : Follow-up : When:_________ Where:__________ CXRay: When: ________________ 2D echocardiogram: When: _____________ Cardiac Rehabilitation Plan of Care and OPD Follow-

up______________________________ ACTIVITY _______________________________ NUTRITION/ DIET :________________________ PARENTS/GUARDIAN UNDERSTOOD, VERBALIZED,


( ) Y ( ) N


NURSING ASSESSMENT: Braden Risk Score: ____________________ General Pain Assessment: ______________ NIPS – FACES: ________________________ Fall Risk Score: _______________________ Post-op Wound Assessment ____________

INTERPRETATION:

OUTCOME GOALS Stable Vital signs Discharge to Home Parents accomplished and

submitted Satisfaction Survey Form

Philhealth form accomplished and submitted

( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N ( ) Y ( ) N


DISCHARGE CHECKLIST

Discharge summary

Patient Satisfactory Survey Form

TOF Data base form

Philhealth Form Submitted

Medication Reconciliation Form (MRF) Accomplished


DISCHARGE PLANNING Date of Discharge: ___________________________

A__ B__ C__ D__

ACTIVATED BY:

Signature over Printed Name ATTENDING PHYSICIAN/FELLOW-ON-DUTY Date/Time____________

ACKNOWLEDGED BY:

Signature over Printed Name NURSE-IN-CHARGE (AM Shift) Date/Time_________________

____________________________________ Signature over Printed Name NURSE-IN-CHARGE (PM Shift) Date/Time________________

VARIANCE CODE










9. Other reasons

PHILIPPINE HEART CENTER East Avenue, Quezon City · PDF file · 2004-12-31episodes...

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