Download ACPCF Recommended Annual Review Proforma

Name:
Hospital No:
DOB:
1
ACPCF Suggested Inclusion for Annual Review
Date of Issue:
Review Date:
May 2010
May 2011
Author:
Liz MacIntosh
Contact details:
Physiotherapy Department
Royal London Hospital
2nd Floor Fielden House
Whitechapel
London E1 1BB
Tel: 020 7377 7000, bleep 1081
Email: [email protected]
Contributors:
Katie Ferguson, ACPCF Committee Member, Kings
College Hospital
ACPCF Committee 2009
Contents:
Introduction
Purpose of this paper
References
Introduction
National guidelines1,2&3 recommend all specialist CF centres and CF clinics should aim to
provide a comprehensive annual review. The CF Specialist Physiotherapists should carry
out an annual review on all children and adults with cystic fibrosis (see CF Trust “Standards
of Care”1, CF Trust “Clinical Guidelines for the Physiotherapy Management of Cystic
Fibrosis”2 and the ACPCF “Clinical Guidelines”3 for more information).
This document makes suggestions to guide physiotherapists during their annual review of
children and / or adults with cystic fibrosis. It is comprehensive, and physiotherapists are not
expected to complete it all within one annual review sitting. However, elements of the form
can be utilised, according to your centres specific aims, and within the time limitations.
This document has been written by members of the ACPCF South East Regional members4
and approved by the ACPCF committee.
Signature:
Printed Name:
Date:
Name:
Hospital No:
DOB:
2
Purpose of this Document
This document aims to act as a useful tool and reference document for all physiotherapists
involved in the delivery of care to people with cystic fibrosis. Annual review assessments are
used to enable physiotherapists to carry out an in-depth assessment on their child or adult
with CF. It enables physiotherapists to:






Gain a baseline on their current clinical status
Review their airway clearance technique and adapts / modifies as necessary
Review their inhalation therapy
Gain an understanding of their exercise tolerance (including use of an exercise test as
an outcome measure)
Identify other problematic areas e.g. compliance, postural problems, urinary
incontinence
Make short and long-term plans / goals to guide future practice.
The document may in the future act as a source of information and data collection of
physiotherapy related problems and treatments in CF to facilitate research and audit in this
speciality
References
1.
2.
3.
4.
Cystic Fibrosis Trust (2001). Standards for the Clinical Care of Children and Adults
with Cystic Fibrosis in the UK. The CF Trust’s Clinical Standards and Accreditation
Group.
Cystic Fibrosis Trust (2002). Clinical Guidelines for the Physiotherapy Management of
Cystic Fibrosis. ACPCF recommendation of a working group.
Association of Chartered Physiotherapists in Cystic Fibrosis (2009). National
Standards of Care.
Consensus opinion – South-Eastern Region Physiotherapy Group.
Signature:
Printed Name:
Date:
Name:
Hospital No:
DOB:
3
Suggestions for Inclusion in Annual Review
Others present:
Complete / update database: Y / N
Consultant:
Informed consent gained: Patient / parent
Shared Care: Y / N _________________
Date or Annual Review
Past Medical History
Liver □
Port □
Diabetes □ Gastrostomy □
PI □
Gut □
Chest □
Weight □
Social □
Other:
No. of courses of ABx over past yr
IVs:
Oral:
Recent cultures:
Previous Microbiology:
Reason for last
admission:
Date:
Respiratory meds:
Current additional antibiotics:
Portacath insertion: Y / N
Parenteral feeding (PEG): Y / N
Gastroesophageal Reflux: Y / N
Liver dysfunction: Y / N
Sinus problems: Y / N
Hay fever: Y / N
Stress incontinence: Y / N
Glucose tolerance problems / CFRD: Y / N
Bone density impaired: Y / N
Any fractures: Y / N
Any other information (e.g. CXR findings, ABG results, NIV, overnight oximetry):
Subjective Assessment
Subjective / Present Condition (including current respiratory status)
Overall respiratory
symptoms
(compared to prev. yr)
Cough
(compared
to prev. yr)
Nil □
Increased □
Decreased □
ISQ □
Clear □
White □
Cream □
Yellow □
Green □
Brown □
N/A □
Sputum quantity in
one physio session
Sputum
colour
Signature:
Cough
pattern
Sputum
appearance
Better □
Worse □
ISQ □
Variable □
Morning □
Evening □
Night □
Intermittent □
With physio □
Other:
Nature of
cough
Salivary □
Frothy □
Purulent □
Pluggy □
Tenacious □
Loose □
N/A □
Haemoptysis
Yes □
No □
Details:
Sputum
quantity in
24 hours
Nil □
Less than 5 mls □
5-10 mls □
10-20 mls □
More than 20 mls □
Variable □
Nil □
Less than 5 mls □
5-10 mls □
10-20 mls □
More than 20 mls □
Variable □
Printed Name:
Productive (expectorates) □
Productive (non expectorates) □
Non Productive □
Paroxysmal □
Other:
Date:
Streaking □
Frank □
Name:
Hospital No:
DOB:
4
Same as peers □
More than peers □
Unable to exercise due to SOB □
Coughing on exercise □
SOBAR: Y / N
SOBOE
MRC Dyspnoea
scale (degree of
breathlessness
related to
activities)
1. Not troubled by breathlessness except on strenuous exercise.
2. Short of breath when hurrying or walking up a slight hill.
3. Walks slower than contemporaries on the level because of breathlessness, or
has to stop for breath when walking or at own pace.
4. Stops for breath after walking about 100m or after a few minutes on the level.
5. Too breathless to leave the house, or breathless when dressing or undressing.
(please circle)
Early morning headache:
Y/N
Comments:
Wheeze: Y / N
Trigger:
Nil known □
Cold □
Exercise □
Pets □
URTI / LRTI □
Other:
Relieved
Nil □
Rest □
Bronchodilator □
Other:
Smoking
Parents / Family / Partner: Y / N
Patient: Y / N
Comments:
How many / day:
Smoking cessation advice provided: Y / N
Additional Information / Quality of life issues / Changes:
Objective Assessment
Spirometry Actual pre
Actual post
B/D
B/D
FEV1
FVC
MMEF
PEFR
Comments (e.g. technique, reliability):
SaO2
Last yrs SaO2
Posture
Predicted
% predicted
Last year’s
% predicted
% Chest shape Normal □
Auscultation:
%
Hyperinflated □
Other:
Normal □
Kyphosis □
Kypholordosis □
Flat back □
Sway back □
Protracted shoulders □
% change
following B/D
Breathing pattern
(include any signs of resp
distress):
Detailed assessment findings (e.g. head position, sh & Tx ROM, muscle
length / strength changes, neuro-muscular control, plumb line, chest pain, chest wall
stiffness, are you able to stand as straight as last year? Use a separate page for more
info, e.g. body diagram / flexi curve results / photos):
Does this cause back pain? Y / N
Further musculoskeletal assessment required? Y / N
Signature:
Printed Name:
Date:
Name:
Hospital No:
DOB:
5
Urinary Incontinence:
Y/N
When:
Coughing □
Amount
Laughing □
Exercising □
Other:
Few drops in
underwear □
Dribbles
down leg □
Fully empties
bladder □
Other:
Comments:
Teach pelvic floor: Y / N
Other management:
Equipment
Electronic
Pari E-flow rapid □
device /
Profile I-neb □
compressor Pari Junior Boy (green) □
Pari Turbo Boy (black) □
Pari Uni-light Mobil □
Other:
Inhalers used
Nebuliser Pari LC plus □ Drugs via
Pari LC star □ nebuliser
Filter system □
i-Neb □
e-flow □
Econoneb □
Actineb □
Other:
Accuhaler □
Turbohaler □
MDI □
MDI + spacer □
Other:
Drugs by inhaler
DNase □
Colistin □
Promixin □
TOBI □
Salbutamol □
Hypertonic Saline □
Other:
Bronchodilator □
Steroid □
Combi □
Other:
Check inhaler technique: Y / N
Check nebuliser technique: Y / N
Comments:
Comments:
Servicing arrangements for equipment (Who,
Cleaning / sterilising routine adequate: Y / N
Comments:
where, when last serviced):
Timing of inhaled medications / nebulisers /
physiotherapy treatment discussed so
optimum: Y / N
Any other equipment required: Y / N
If no, re-education given: Y / N
If so, what was supplied:
Equipment supplied today: Y / N
Physiotherapy
Technique
ACBT □
AD □ / Passive AD □
PEP: Mask □ Pari □ Bubble □
Flutter □
Acapella □
Manual techniques & PD □
Exercise □
HFCWO □
Other:
Signature:
Frequency
Printed Name:
Duration
When unwell
Date:
Name:
Hospital No:
DOB:
6
Self □
Mother □
Father □
Other:
Any problems with usual ACT
Usual treatment
by
Sample sent
Observation of technique:
Sinus problems □
Signs of reflux □
Compliance □
Other:
Sputum: For MC&S □
Cough swab □
NPA □
Cough plate □
Gastric aspirate □
None sent □
For AFBs □
Sputum colour / appearance:
Exercise
Preferred
activities and
sports
Barriers to exercise:
Intensity,
frequency and
duration
Location (e.g. at
Occupation:
home, at school, in
gym)
Does this include physical activity:
Tolerance
Better than peers □
Same as peers □
Able to fully participate, but less than peers □
Can only participate in some activities □
Ability to exercise fairly limited □
Breathless on walking, does not participate in formal exercise □
Precautions to
exercise
Acute exacerbation □
Arthropathy □
Hypoxia □
Exercise induced asthma □
Intestinal obstruction □
Portal hypertension, enlarged spleen & liver □
Pneumothorax □
Low bone density □
Air trapping and sinus disease □
Severe haemoptysis □
Pyrexia □
Special advice:
Exercise testing
Is it appropriate to do any testing today: Y / N
If no, reason why not:
Poor cooperation □
Insufficient time for test □
If so, which exercise
10 m shuttle walk test □
test carried out:
Modified incremental shuttle walking
test □
Signature:
Printed Name:
Current exacerbation □
Other:
3-minute step test □
Other:
Date:
Name:
Hospital No:
DOB:
7
Modified Incremental Shuttle Walking Test
SpO2
Heart Rate
Rate of Perceived
Exertion (Borg)
Respiratory Rate &
Respiratory Pattern
Pre-test (resting)
During
Post test
Recovery (1 min)
Recovery (2 mins)
Recovery (5 mins)
Level
1.
/
2.
/
3.
/
4.
/
5.
/
6.
/
7.
/
8.
/
9.
/
10. /
11. /
12. /
13. /
14. /
15. /
Shuttles per level
/ /
/ / /
/ / / /
/ / / / /
/ / / / / /
/ / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Total in metres
(30)
(70)
(120)
(180)
(250)
(330)
(420)
(520)
(630)
(750)
(880)
(1020)
/
(1170)
/ /
(1330)
/ / /
(1530)
Number of completed levels:
Total Distance:
Reason for stopping:
Number of Shuttles:
Lowest SaO2 recorded:
Interpretation of exercise test results:
Consideration for oxygen therapy:
Recommendations following exercise test:
Date to repeat exercise:
10 m Shuttle Walk Test
SpO2
Heart Rate
Rate of Perceived
Exertion (Borg)
Pre-test (resting)
During
Post test
Recovery (1 min)
Recovery (5 mins)
Comments (including total distance travelled):
Signature:
Printed Name:
Date:
Perceived Muscular
Effort (Borg)
Name:
Hospital No:
DOB:
3 min Step Test
Criteria
8
6 years plus: Y / N
SpO2
Trained in test: Y / N
Heart Rate
Rate of Perceived
Exertion (Borg)
Perceived Muscular
Effort (Borg)
Pre-test (resting)
During
Post test
Recovery (1 min)
Recovery (5 mins)
Comments:
15 second count All in 1 breath □
pre-test
1 extra breath taken □
2 extra breaths taken □
3 extra breaths taken □
More then 3 breaths taken □
15 second count
immediately post
test
All in 1 breath □
1 extra breath taken □
2 extra breaths taken □
3 extra breaths taken □
More then 3 breaths taken □
Summary
Clinical Evaluation
Suggestions / Changes Made
Handouts Provided
AD / Passive AD □
PEP / Baby PEP □
Acapella / Flutter □
Bubble PEP □
Manual therapy & positioning □
ACBT □
Other:
HFCWO □
Exercise □
Posture □
Incontinence □
Nebuliser info sheet □
NIV □
Clinic Meeting – decisions / actions
Signature:
Printed Name:
Date:
Name:
Hospital No:
DOB:
9
Further action plans following Annual Review (date & sign)
Reviewed Physiotherapy SMART Goals / Plans (date & sign)
Signature:
Printed Name:
Date: