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Coronary Heart Disease _CHD_

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					Coronary Heart Disease
        (CHD)

   A Nurse’s Perspective


      Gloria Clayton
    STATISTICS OF CHRONIC
           DISEASE
• More than 70% of Australia’s disease
  burden is attributed to chronic disease and
  is expected to reach 80% by 2020.

• If the major risk factors for chronic
  diseases were eliminated, 80% of heart
  disease, stroke and T2 Diabetes Mellitus
  would have been prevented.
       CHRONIC DISEASES
• Are complex and with multiple causes
• Although more prevalent with age, can
  occur at any time during life cycle.
• Long term, persistent and affect quality of
  life.
• Are frequently improved by lifestyle
  modification
LIFESTYLE ACTIVITIES RETARDING
            HEALTH
•   Smoking
•   Nutrition-poor or incorrect diet
•   Alcohol
•   Physical inactivity
•   Weight in excess
•   Elevated Blood Pressure
•   Elevated cholesterol
           MANAGEMENT OF CHD IN THE
                CLINIC SETTING
•   What is disease management

•   A care system without boundaries to provide gold standard care for patients
•   Best for well understood conditions
•   Guidelines Who          What Where       to whom        GP Podiatrist
•                   Nurse GPMP Clinic         Patient       cardiac rehab etc
•   A continuous quality improvement process
•   Encourages patient with help of a Registered Nurse and others to set achievable
    goals to affect change.
  RUNNING NURSE LED CLINICS
• Purpose

• To improve patient care by recruiting identified at risk patients of
  clinic, and implementation of planned recalls.
• To save GP time to better make the medical decisions
• To allow patients time to question, voice concerns, attain answers,
  gather or request literature, and be a partner in setting realistic goals
  for effective lifestyle changes.

• Nurses write up GPMP’s for completion by GP, which is then printed
  off for the patient to keep, and have handy at all times.
• To monitor risk factors
• To screen for Depression/Anxiety using PHQ9 or HADS.
             PLANNING THE CLINIC
• Desired:                               Equipment:
•   Protected time, apart from           PC with electronic medical record access
    routine nursing duties.
                                         Blood Pressure Monitor (large & small cuffs
    Negotiated with Practice
                                         should be available)
    Manager or GP.
•   Good receptionist who knows the      Scales
    system, for recall protocol, who     Tape Measure (large)
    knows about billing, TCA’s,
    EPC’s and then gives out             Foot care filaments
    questionnaires e.g. mood tools,      Check lists
    medication and activity enquiries.
                                         Education Material- food diary, Heart
                                         Foundation literature, cardiac rehab etc.
                                         Contact Lists for allied health-care providers of
                                         services, e.g. cardiac rehab, podiatrists,
                                         dietitians, dentists & optometrists etc.
                                         Patient folders for copies of plans and other
                                         literature. Access to Doppler and ECG
                                         equipment.
               RUNNING THE CLINIC
                                      •   Yearly Dopplers for
•   Initial clinic appointment 45         PVD/Diabetes patients.
    mins. Follow ups 15 mins.         •   Yearly ECG for CHD pts and
    Annual check 45 mins.                 depending on MO for
•   Explain Role of Registered            Diabetics as well.
    Nurse.                            •   Foot check. Examination of
                                          feet noting toenails, callus,
•   Check Depression/Anxiety              sensation & skin colour. Done
    score                                 6 monthly. (Use Nylon
                                          monofilament no 4)
•   Explain Investigation Results
                                      •   Notation of last eye check,
•   Check pathology results e.g.          allied health & specialists.
    E.LFT’s Cholesterol Glucose       •   Lifestyle checklist- encourage
    TFT’s yrly if on Thyroxine.           patient in regards setting own
    Digoxin trough if on Digoxin.         goals e.g. exercise & diet, with
                                          help of a registered nurse.
    (Collected 6hrs post last dose,
                                      •   Recall and review dates-
    or pre next dose.)                    Appointment made by RN. 3
•   Measurements: weight, height,         months if high risk, recent
    waist & Blood Pressure                cardiac event, medication
                                          changes, off target or
                                          depressed.) Low risk 6mths.
                                      •   Hand out relevant literature.
APPROXIMATE TIME SCHEDULE
• 0-5 mins- meet, greet & explain
• 5-10mins- review depression score and pathology with
  explanation.
• 10-15mins- measure blood pressure, height, weight, waist
  and feet.
• 15-25mins- doppler
• 25-35mins- discuss goals, other matters of concern e.g.
  new appointments.
• 35-45mins- date recall, appointment made. Education
  material to patient. Write up plan. Do TCA’s or EPC’s if
  necessary and phone.
            CYCLE OF CARE
DISEASE       3 MTHLY           6 MTHLY            ANNUAL




CHD                             E/LFT’s, lipids,   Add TFT’s if on
                                esp HDL, glucose   Thyroxine.
                                                   Digoxin trough if
                                                   on Digoxin.

T2DM          HbA1c, E/ LFT’s   Lipids, HDL        Microalbumin
                                Glucose




 Cholesterol should be as low as possible.
WHY INCLUDE MENTAL HEALTH
• WHO Statistics show that depression is missed in 75%
  of GP consults, when patients have a significant medical
  condition.
• Limestone Coast statistics show that 17% of our
  Diabetics pts had mild depression and 15% had clinical
  depression. Similar statistics also exist for CHD.
• Untreated depression is as more a risk factor as
  continuing to smoke, or having high cholesterol, and
  more of a risk than elevated blood pressure or being
  obese. Facts show that patients are 4 times more likely
  to die in the first 6 months post heart attack if they are
  depressed.
Avoid taking patients problems on board
personally. Concentrate on positives.
Remember future chances exist to make
a difference if rapport established.
                     PLANS
• Patients are encouraged to take GP Management Plans
  to any health appointment they may attend.
• HOSPITAL= for current medications and health status
• HOLIDAYS= If becomes ill while away, GP’s in other
  areas find GPMP’s to be a useful aid in knowing what
  was normal for the patient when last seen regular MO.
• FAMILY= To know about the disease, encourage
  discussion and promote understanding.
• HOLIDAYS & HOSPITAL= pack GPMP when packs
  toilet bag, keep together

				
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