_CHD_Self Management Plan _721_ by shitingting


									         CORONARY HEART DISEASE (CHD) SELF MANAGEMENT PLAN – 721                                                                                               REVIEW – 725
                  Applies to acute coronary syndromes, myocardial infarction, coronary angioplasty with/without stenting, and bypass surgery.

                                       [LOC_NAME] Phone: [LOC_DAY_PHONE] fax: [LOC_FAX_PHONE]

Patient Details                      GP Details:                 Patient agreement for the GP Management Plan proceed
[PAT_FIRSTNAME] [PAT_SURNAME]        [GP_GIVENNAME]              My GP has explained the steps & costs of the GP Management Plan & I agree to proceed.                                Yes
[PAT_HOME_STREET],                   [GP_SURNAME]
[PAT_HOME_POSTCODE],                 [GP_REG_NO]                 Where I am referred to other service providers as listed on this GP Management Plan, I consent to my GP sharing      Yes
[PAT_HOME_STATE]                                                 relevant information about myself to that provider. I have advised my GP of any information I wish to be withheld.
DOB: [PAT_DOB]                                                   I understand that [LOC_NAME]        has one health record for patients and that this record is shared by       Yes
                                                                 all [LOC_NAME]       health team providers.                                                                                .

 Nature of the disease, Risk Factors and Co-morbidities (What is my condition?)

If you have coronary heart disease, the blood vessels that carry oxygen and nutrients to your heart muscle are clogged and narrowed. If these vessels (the
coronary arteries) become too clogged, the blood supply to your heart muscle is reduced, which can lead to symptoms such as angina. If a blood clot forms in
the narrowed artery and completely blocks the blood supply to part of your heart, it can cause a life-threatening heart attack.

 Impact of the Disease (what are my symptoms?)
 You may have just one of these symptoms, or you may have a combination of them. Symptoms can come on suddenly or develop over minutes and
 get progressively worse. Symptoms usually last for at least 10 minutes.

 Discomfort or pain in the centre of your chest: this can often feel like a heaviness, tightness or pressure. People who have had a heart attack have commonly
 described it as like an “elephant sitting on my chest” or “a belt that’s been tightened around my chest.” The discomfort may spread to different parts of your
 upper body.
 Discomfort in these parts of your upper body: Arms, shoulders, neck, jaw and back. You may have a choking feeling in your throat. Your arms may feel
 heavy or useless.

 You may also experience other signs and symptoms:
    – feel short of breath
    – feel nauseous
    – have a cold sweat
    – feel dizzy or light-headed.

If above symptoms appear

1 STOP and rest

2 Talk to somebody and tell them how you fell
symptoms are severe? or getting worse? or lasted 10 minutes?
(If you take angina medicine: • Take a dose of your medicine, Wait 5 minutes. Still have symptoms?Take another dose of your medicine. • Wait 5 minutes.
Symptoms won’t go away?)

3 CALL 000 Ask for an ambulance. • Don’t hang up. • Wait for the operator’s instructions. (*If calling Triple Zero (000) does not work on your mobile
phone, try 112.)

                                                                                MANAGEMENT PLAN
                      (Unless otherwise indicated, all recommendations derived from National Heart Foundation of       My role in this care plan and Lifestyle changes   Who will
     Medicine         Australia and the Cardiac Society of Australia and New Zealand. Reducing risk in heart disease                                                     do this?

Antiplatelet agents   Use aspirin 75–150 mg/day for all patients unless

ACE inhibitors        Consider ACEI in all patients, especially those at high risk,
(ACEI)/Angiotensin    unless contraindicated. Start early post myocardial infarction
II receptor           (MI). Consider ARA for patients who develop unacceptable side
antagonists (ARA)     effects on ACEI.

Beta-blockers         For all patients post MI, unless contraindicated, and continued
                      indefinitely, especially in high-risk patients.
                      (High-risk patients are defined as those with either significant
                      myocardial necrosis, left ventricular systolic dysfunction,
                      persistent evidence of ischaemia or ventricular arrhythmia.)
Statins               For all patients with CHD, unless contraindicated.

Anticoagulants        Use warfarin in patients at high risk of thromboembolism
                      post MI.

Aldosterone           Epleronone may be used early post MI in patient with left
antagonists           ventricular systolic dysfunction and symptoms of
                      heart failure.

Medicine adherence If poor adherence suspected, consider a Home Medicine Review.


Lifestyle/Psychosocial risk factors
                                             Recommendations                                                                                Who will do
    Risk factor                                                                           My role in this care plan and Lifestyle changes
                                                and targets                                                                                   this?
Smoking               Complete cessation
                      and avoidance of second-hand smoke.

Physical inactivity   Progress, over time, to at least 30 minutes of moderate-intensity
                      physical activity on most, if not all, days of the week (150
                      minutes per week minimum).

Nutrition             Establishment/
                      Maintenance of healthy eating patterns, with saturated and trans
                      fatty acid intake ≤ 8% of total energy intake.

Weight                Waist measurement
                      ≤ 94 cm (males) or
                      ≤ 80 cm (females);
                      BMI = 18.5-24.9 m2.

Alcohol               Low risk alcohol consumption in people who drink < 2 standard
                      drinks per day (males) or < 1 standard drink
                      per day (females).
Depression           Assess all patients for co-morbid depression. Initiate
                     psychosocial and medical management if appropriate.

Social support       Assess all patients for level of social support and provide follow-
                     up for people considered at risk by referral to cardiac
                     rehabilitation and/or social worker or psychologist.


Biomedical risk factors
                                          Recommendations                                                                                    Who will do
   Risk factor                                                                             My role in this care plan and Lifestyle changes
                                              and targets                                                                                      this?
Cholesterol/Lipids LDL-C < 2.0 mmol/L; HDL-C > 1.0 mmol/L; Triglycerides
                   < 1.5 mmol/L.
Blood pressure     BP < 130/80 mmHg. For people with proteinuria > 1 g/day (with
                   or without diabetes):
                   < 125/75 mmHg.
                   (National Heart Foundation of Australia. Guide to management of
                   hypertension 2008.)
Diabetes           Identify undiagnosed type 2 diabetes; maintain optimal BSL in
                   those with diabetes (HbA1c ≤ 7%).
Other conditions

Capacity to self manage
    I have explored readiness for change and barriers for self management
    I have checked that the patient has enough knowledge, confidence and family support to manage the condition

Contacts and further Information

For heart health information 1300 36 27 87 www.heartfoundation.org.au
A copy of this plan has been given to the patient.   Yes   This section is only to be completed at Review appointment
Charge item 721                                            Review Date
Enter recall for review 6 months
Enter recall for new plan 2 years                          Enter recall for review 6 months

DATE COMPLETED: [MIS_TODAYL]                               Claim item 725

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