PATIENT CARE PLAN - Mersey Renal Units · 1 Aintree renal patient care plan January 2013.Lead: Dr B K Pandya Nephrology Directorate. the hospital or on holiday You must update your

1 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya

Nephrology Directorate

Aintree Kidney Patient Care Plan Chronic Kidney Disease (CKD)

Please TAKE this Care Plan with you to anywhere you visit: whether to the surgery, in the hospital or on holiday. This will make the health team aware about your health problems and your Medications. You or a member of your health team can update your care plan after each visit with any changes in your care. You must update your Medications list immediately if any changes are made. Name of Lead for care plans: Dr Bhavna Pandya, Consultant Nephrologist, Aintree University Hospitals.


CARE PLANNING is about addressing an individual’s full range of needs delivered by primary care, hospital, community and social health care professionals, to provide holistic approach to empower and self manage his or her care. Care plan is a document containing individual’s health problems, medications list, treatment plans and contact numbers. You have been given your care plan book at reception. If you already have one please return it back to reception. Please give your care plan book to the clinician when you see them. They will complete the relevant pages at your first visit. HOW TO USE your care plan book: The information below will guide you about each page and how it can be filled in. Front page: General info about care plan. Page 3: Your details- please complete your address details and the phone no, while you wait to see the clinician. Consultant details will be filled in by clinician at bottom of page. Page 4: Details of your diagnosis will be filled in by your clinician. In the remaining space available any future new diagnosis can be added on. Page 5: Vaccine - please contact your surgery or nurse practitioner for details to fill that section in. We will update your immunity results for you when available. Page 6: Contains some definitions and explains some terminologies used on this book. Page 7: Lists the patient information leaflets and the date they are discussed or given out. You or your clinician can tick and put the appropriate date. Page 8-11: Please list the medications and dose. Please make sure you update this regularly for any changes made at GP Surgery and/or Hospital. Page 12: Please record your blood pressure and the date each time you check. Page 13: Record of your weight and the date when relevant. Page 14: Some definition and explanation of your relevant kidney blood test. Page 15: Know your numbers- the results can be recorded by yourself or your clinician.


Page 16: Treatment options to be completed by your clinician when discussions and decisions are made for transplant, dialysis or non- dialysis treatment when relevant. Page 17: This is your diary where you can fill in your appointment dates. Page 18-19: You can request your clinician or nurse to summarise the plans when you get discharged from hospital. Page 20-26: These pages are for you or your health team to fill in according to agreed targets and objective plans. Page 27: Advance Care Planning when relevant. Page 28: You can request other health professionals to add their comments when you visit their appointments for better communication. Page 29: This page is designed to write down the points regarding any questions or queries you may have and want to ask your health team. Page 30: For any notes you want to make. Page 31: Some contact details of our department. Page 32: General information sites including any patient support groups.

Patient Details

UNIT NUMBER___________________________ NAME______________________________ DOB_______________________________ ADDRESS___________________________________________________________________ TELEPHONE NUMBER___________________________ My blood group is _______________________ My GP Name and address __________________ _______________________________________


CONSULTANT_ TEAM 1 Dr Abraham, Dr Wong, Dr Goldsmith Team 2 Dr Pandya, Dr Chandrasekar, Dr Sharma

CKD STAGE_____ eGFR _______Date _________ POSSIBLE DIAGNOSIS________________________ OTHER DIAGNOSES_________________________


Vaccinations FLU Dates: _______; ________; _______; ______

_______; ________; _______; ______ PNEUMOVAX Dates: ____________; ___________ HEPATITIS B VACCINE COURSE: Dates and Dose: 1 _________Dose_________

2 _________Dose_________ 3 _________Dose_________

Hep B Antibody check

Booster date

Date Titre


Definitions and meanings Here is brief information regarding some of the terminology you will come across during the course of your illness as a kidney patient. The detailed information is available in an individual leaflet. Kidneys purify blood by throwing out toxins via urine while retaining blood, protein and other important substances in body. Renal Patient View (RPV) provides online information about renal patients' diagnosis, treatment, and their latest test results. Patients can share this information with anyone they want, and view it from anywhere in the world. CKD (Chronic Kidney Disease) is a term used to describe structural or functional deficit of the kidneys. CKD stages: There are 5 stages of CKD: stage 1 the least severe and stage 5 the most severe when you may need support for your kidneys. eGFR (Estimated Glomerular Filtration Rate) is an estimation and rough representation of % functions of the kidneys. Anaemia means there are not enough red blood cells in your blood. This is measured as haemoglobin. In kidney patients a substance called erythropoietin which helps formation of red blood cells is produced less from the kidneys. Calcium and bone: Kidneys produce vitamin D which helps body to maintain calcium and phosphorous substances to keep bones healthy. Dialysis is a type of treatment given to patients to clean their blood when kidney functions go down to less than 10%. Haemodialysis is carried out via blood passing through the machine and then returned back in the body. Peritoneal Dialysis is carried out via fluid introduced in the abdomen and then drained out. Vascular access is the term used for a tube inserted in to the vein or creation of a fistula by connecting an artery and a vein for haemodialysis Transplant of Kidney from another individual is considered when the kidneys do not function. (PDA) Patient Decision Aid: These are the resources given out to the patients which help them make the decision for their treatment for example type of dialysis or kidney transplant. Kidney Biopsy is a procedure when a piece of kidney tissue is taken out for the purpose of diagnosis of kidney disease. Potassium is a substance which we consume in our diet. It accumulates in the body when kidney functions are significantly reduced. Very high levels of potassium can cause various complications including sudden death.


Patient Information Leaflets Topic Leaflet given Discussion Date

Renal Patient View (RPV) General Info + Chronic Kidney Disease (CKD)

Know Your Numbers You and Your Medicines

Anaemia Erythropoietin therapy

Calcium and Bone Chemistry Haemodialysis / Peritoneal dialysis/conservative (Non-dialysis) therapy

CKD Stage V treatment options

Vascular access Transplant Patient Decision Aid (PDA) Concise guide Full guide

Kidney Biopsy Stop Gap Potassium Dietetic leaflets (From Dietitian)

1.

2.

3. 4.

Planning for your future care [Advance Care Planning (ACP)]

Please ask any questions regarding information given in this booklet or any other subject to the doctor/nurse in clinic.

This will help you understand your treatment plan. Some of the information in this care plan may not be relevant to you. Please remember that each patient with kidney disease will have different problems and treatment plans.


Please keep your MEDICINES record up to date by asking the doctor / nurse to fill in the list IF they make any changes to any drug.

Allergies:

Drug Name Dose Frequency

For Hospital Use

Date changed or stopped

Reason

Aranesp Dose

Freq. Date

Venofer / Cosmofer

Dose Freq. Date


Drugs to Avoid: NSAIDs (Strong Pain killers) Nephrotoxic agents Trimethoprim



Reason

Aranesp Dose

Freq. Date

Venofer / Cosmofer

Dose Freq. Date




Reason

Aranesp Dose

Freq. Date

Venofer / Cosmofer

Dose Freq. Date




Reason

Aranesp Dose

Freq. Date

Venofer / Cosmofer

Dose Freq. Date


Blood Pressure Record

Date BP Date BP Date BP


Weight (Kg) Record

Date Weight Date Weight Date Weight


KNOW YOUR NUMBERS Brief information

(The details given below is only brief for your basic knowledge and do not include all the points. The detailed information is available in relevant leaflets. Please ask your doctor or nurse if necessary)

eGFR (Estimated Glomerular Filtration Rate) is an estimation and rough representation of % functions of the kidneys. Creatinine is a substance which represents the toxins thrown away by the kidney via urine. The level of creatinine increases as kidney functions decline. Potassium is a substance which we consume in our diet accumulates in the body when kidneys functions are significantly reduced. Very high levels of potassium can cause various complications including sudden death. Bicarbonate is a measure of acid status in the body. Kidneys produce bicarbonate to titrate acid produced normally in body. Bicarbonate level is reduced when kidney functions deteriorate. Calcium: Kidneys produce vitamin D which helps the body to maintain calcium to keep bones healthy. Calcium levels can be low when kidney functions are reduced. Phosphate: Phosphate is consumed in the diet. Kidneys help to throw away extra phosphate from the body via urine. When kidney functions are reduced to around a quarter or less, phosphate accumulates in the body and levels are raised. PTH (Parathyroid Hormone): This hormone mainly maintains body’s calcium and phosphate balance. The level increases in response to low calcium and high phosphate in body. Increased PTH levels make bones brittle and arteries thicken. Haemoglobin is a measure of red blood cells in blood. In kidney patients a substance called erythropoietin, which helps the formation of red blood cells is produced less from the kidneys. This means less number of red blood cells are produced in the body. This condition is called anaemia. 24 hours urine protein or ACR (Albumin Creatinine Ratio) test measures proteinuria which means leakage of protein from kidneys in urine.


KNOW YOUR NUMBERS

Note-The values *(in bracket) suggest accepted range for CKD patients as per Renal Association UK guidelines. +The value indicates normal laboratory range only and

significance varies with eGFR value.

Test eGFR (>90/1.73m2 ml/min)

Creatinine+

(0-150 μmol/L)

Potassium* (3.5-5.9 mmol/L)

Bicarbonate (22-30 mmol/L)

Date

Test Calcium

(2.18-2.62 mmol/L)

Phosphate (0.7-1.6 mmol/L)

PTH (<1.3-6.8 pmol/L)

Haemoglobin *(105-125g/L)

Date


Treatment Options Renal Replacement Therapy (RRT)

MODALITIES DISCUSSED (If appropriate) Modality Discussion

Date Chosen Date

Transplant Peritoneal Dialysis (PD) Haemodialysis (HD): Home Haemodialysis (HD): Hospital Conservative (Non-dialysis management)

SUITABLE FOR TRANSPLANT LIST Y / N REASON ___________________________ DATE LISTED _______________________ SAVING VEINS IN; LEFT ARM / RIGHT ARM


APPOINTMENTS Next Appointments

OPD/ Ward review/ Blood tests

DATE OPD/ Ward review/ Blood tests

DATE


Discharge Plans

Date Plans


Discharge Plans

Date Plans


My Personal Health Plan The points below are the examples that you and your health care professional might want discuss for your care planning. There are blank areas in the next table for you to include the points important for you and not already listed. Health related issues or concerns:

Results Treatment information Treatment choices: Transplant, Dialysis, No-dialysis therapy My kidney disease

Changing my treatment My other health concerns Changing dialysis modality Stopping dialysis or any other

Non-Health related issues or concerns:

Holidays Money or benefits Work or study related issues Food or drink Exercise or fitness activity related Other

Multi-Disciplinary team input

Dietician Social worker Physiotherapy Other teams: Radiology Clinical Psychology

Any other issues or concerns


Care Planning Targets and Objectives

Date : Team/professional

Goal (How would I like things to be different)

Targets (Where do I want to be?)

Plans (My care team to do)

Plans (What do I need to do?)

Difficulties

To achieve by (date)

Achieved (date)



Date: Team/professional





Difficulties


Achieved (date)



Date : Team/professional





Difficulties


Achieved (date)








Difficulties


Achieved (date)








Difficulties


Achieved (date)








Difficulties

To achieved by (date)

Achieved (date)


Planning for My Future Care [Advance Care Planning (ACP)]

Date By Initial ACP discussion

Written information given

Completed ACP Review of ACP 1. 2. 3. 4. 5.

My personal Plan (Points I would like my care team to be aware of about me):


Multidisciplinary notes

Date Other (non-renal) team comments

Signature


Any other issues for discussion

Issue or concern if resolved Date

Holidays Work or study


Notes


CONTACT TELEPHONE NUMBERS

Dr PANDYA/Dr ABRAHAM’S SECRETARY 529 8796

Dr WONG/Dr GOLDSMITH’S SEC 529 3356

Dr CHANDRASEKAR/Dr SHARMA’S SEC 529 8797

SOUTHPORT NEPHROLOGY SEC 01704 704 569

WARD 20 & DIALYSIS UNIT 529 8825/3814/3529 WARD 20 PCU (programmed Care Unit) 529 4011

AINTREE FRESENIUS DIALYSIS UNIT 529 8802

WATERLOO DIALYSIS UNIT 920 4280

SOUTHPORT DIALYSIS UNIT 01704 518 980

HOME DIALYSIS NURSES 01515293464 07966882953/07891645444

ANAEMIA AND VASCULAR ACCESS NURSE Sojan Thomas 0151 529 6405, BLEEP-5364

INTERVENTIONAL RADIOLOGY 529 2368

Fax No.s : Aintree - 0151 529 2420, Southport - 01704 704 787

Please contact your renal team member for any cultural issues, the issues related to faith or language or any other issues.


FURTHER INFORMATION Aintree Kidney Unit Website www.aintreerenalunit.nhs.uk

AINTREE KIDNEY PATIENT ASSOCIATION (AKPA) www.aintreekidneypatientsassociation.org.uk – Contact Secretary to Dr Pandya 0151 529 8796

SOUTHPORT KIDNEY FUND http://southportkidneyfund.org/wp/ Mrs. P. Carr 01704 220951 Mrs. J. Coleman 01704 560824 MERSEY KIDNEY PATIENTS GROUP www.merseykidney.org

National Kidney Federation (NKF) www.nkf.org

Website for all Mersey renal units www.merseyrenalunits.nhs.uk

Renal Patient View www.renalpatietnview.org

http://www.aintreerenalunit.nhs.uk/

http://www.aintreekidneypatientsassociation.org.uk/

http://southportkidneyfund.org/wp/

http://www.merseykidney.org/

http://www.nkf.org/

http://www.merseyrenalunits.nhs.uk/

http://www.renalpatietnview.org/

Documents

PATIENT CARE PLAN - Mersey Renal Units · 1 Aintree renal patient care plan January 2013.Lead: Dr B K Pandya Nephrology Directorate. the hospital or on holiday You must update your