Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Epidemiology wikipedia , lookup
Infection control wikipedia , lookup
Public health genomics wikipedia , lookup
Medical ethics wikipedia , lookup
Rhetoric of health and medicine wikipedia , lookup
Patient safety wikipedia , lookup
Adherence (medicine) wikipedia , lookup
GP ACTION PLAN-CHRONIC KIDNEY DISEASE (RED) Macroalbuminuria irrespective of eGFR or eGFR < 30 mL/min/1.73m2 irrespective of albuminuria Goals of management Investigations to determine underlying cause Reduce progression of Kidney disease Assessment of Absolute Cardiovascular Risk Avoidance of nephrotoxic medications or volume depletion Early detection and management of complications Adjustment of medication doses to levels appropriate kidney function Appropriate referral to a Nephrologist when indicated Prepare for kidney replacement therapy if appropriate Prepare for non -dialysis supportive care is appropriate Patient Details Do you identify as Aboriginal and/or Torres Strait Islander? Yes No General Practitioner’s Details Doctor Name: Patient’s Name: Sex: Male Female DOB: Address: Medicare No: Carer’s Details (if appropriate) Practice: Address: Provider No: Date: This Management Plan covers your multiple Chronic Conditions with a focus on Kidney Disease Patient problems / needs / relevant conditions PAST MEDICAL HISTORY <<Clinical Details: History List>> FAMILY HISTORY <<Clinical Details: Family History>> SOCIAL HISTORY <<Clinical Details: Social History>> MEDICATIONS <<Clinical Details: Medication List>> ALLERGIES <<Clinical Details: Allergies>> IMMUNISATIONS <<Clinical Details: Immunisations>> Disclaimer: This template was developed from the resource www.kidney.org.au. It has been modified to local needs by GCPHN. It is up to each individual Doctor to ensure compliance with MBS guidelines. It is up to each Doctor to decide best practice care for each individual patient. Version: February 2016 Patient needs/ Goals- changes to be achieved relevant conditions Required treatments & services including patient actions Arrangements for treatments/ services (What, who) Review, changes made on Date: 1. Kidney Health Check eGFR Current: mL/min/1.73m2 Urine ACR Current: mg/mmol GP to monitor (every 1 to 3 months) Albuminuria present if urine ACR >3.5 mg/mmol in females and >2.5 mg/mmol in males) ≤ 140/90 mmHg Blood pressure Current: mmHg or ≤ 130/80 mmHg in people with albuminuria or diabetes GP to monitor (every 1 to 3 months) Lifestyle modification Pharmacological therapy GP to monitor (every 1 to 3 months) 2. General Patient’s understanding of chronic kidney disease Patient to have clear understanding of chronic kidney disease & patient’s role in management the condition Patient education (list GP/ Nurse resources, assistance given) Chronic disease wellness program-Central intake unit ph: 1300 668 936 Adult community health brochures http://www.kidney.org.au/ Use GCUH Renal OPD referral template. Patient’s understanding of multi-chronic conditions Patient to have clear understanding of their Patient education (list other chronic condition(s)resources, assistance given) List here: Patients and their families or carers Patient’s Patient education (list should receive sufficient information and resources, assistance given) understanding of education regarding the nature of Stage 5 treatment options CKD, and the options for the treatment to for stage 5 CKD (if allow them to make an informed decision appropriate) about the management of their condition. Treatment choice has more effect on lifestyle than it does on mortality or morbidity. A shared decision making approach is highly recommended. This is best supported by a decision aid, such as the My Kidneys My Choice Decision Aid, available at http://homedialysis.org.au/choosing/mydecision/ Advance Health Directive GP/ Nurse GP/ Nurse/ Nephrologist/ Renal Unit Staff 3. Laboratory assessments Biochemical profile including urea, GP/ Nurse (every 1 Disclaimer: This template was developed from the resource www.kidney.org.au. It has been modified to local needs by GCPHN. It is up to each individual Doctor to ensure compliance with MBS guidelines. It is up to each Doctor to decide best practice care for each individual patient. Version: February 2016 creatinine and electrolytes to 3 months) Blood glucose (for people with diabetes) Current: mmol/mol Generally: ≤53 mmol/mol (range 48-58); ≤7% (range 6.5-7.5). Needs individualisation according to patient circumstances (e.g., disease duration, life expectancy, important comorbidities, and established vascular complications). Lifestyle modification Oral hypoglycaemics Gliptins Incretin mimetics Insulin Lipids Fasting lipid profile In adults with newly identified CKD, Refer to CKD Management in General Practice (3rd edition) for advice regarding statin therapy Full blood count evaluation with a fasting lipid profile is recommended. Follow up measurement of lipid levels is not required for the majority of patients See Anaemia (in Common CKD complications) Calcium and phosphate See Mineral and bone disorder (in Common CKD complications) Parathyroid hormone See Mineral and bone disorder (in Common CKD complications) GP/ Nurse (every 1 to 3 months) GP/ Nurse (every 1 to 3 months) 4. Other assessments Absolute www.cvdcheck.org.au Cardiovascular Risk CVD disease risk calculator Lifestyle modification Pharmacological therapy GP/ Nurse (12 monthly review) High: greater than 15% risk of cardiovascular disease within next five years Moderate: 10-15% risk of cardiovascular disease within next five years Low: Less than 10% risk of cardiovascular disease within next five years Oedema GP/ Nurse (every 1 to 3 months) 5. Lifestyle modification Smoking Smoking cessation Quit Line ph: 13 78 48 Clinical guidelines-supporting smoking cessation: a guide for health professionals Quit (Refer to QUIT Line) Request a QuitLine call back Patient to manage GP to monitor (consider medical therapy) Nutrition Consume a varied diet rich in vegetables, fruits, wholegrain cereals, lean meat, poultry, fish, eggs, nuts and seeds, legumes and beans, and low-fat dairy products. Limit salt to < 6 g salt per day (≤100 mmol/day). Limit foods containing saturated and trans fats. See Australian Dietary Guidelines Patient education (list resources, assistance given) http://www.kidney.org.aupatient info Nutrition Education Materials GP to monitor Referral to Accredited Practicing Dietitian for TCA Healthy GC Dietitian List Water intake: See Drink water instead from Kidney Health Australia. Alcohol intake: Limit to < 2 standard drinks/day Patient to manage GP to monitor Patient education (list Patient to manage Disclaimer: This template was developed from the resource www.kidney.org.au. It has been modified to local needs by GCPHN. It is up to each individual Doctor to ensure compliance with MBS guidelines. It is up to each Doctor to decide best practice care for each individual patient. Version: February 2016 Current: National Health Alcohol Guidelines resources, assistance given) GP to monitor Physical Activity: Current: At least 30 minutes moderate physical activity on most or preferably every day of the week. Patient exercise routine (List directions/ instructions given to patient) Patient to implement Referral to exercise physiologist for TCA GCCC health and active site. Weight Current: Your targets Weight: kg Waist cir: cm BMI: kg/m2 Monitor waist & weight Review progress 6 monthly Set new goals 6 monthly (list resources, assistance given) Patient to monitor GP/Nurse to review (12 monthly review) Referral to exercise physiologist, weight management group Medication review Correct use, dosage, compliance of medications to reduce hospital admissions Referral for an and side effects HMR (item 900) MBS descriptor of item 900 Patient Education Referral to community pharmacist GP / Pharmacist to review & provide education Neprotoxic drugs See page 21 of CKD Management in General Practice Avoidance Adjust medication doses to levels appropriate for kidney function (i.e. kidney metabolised/ excreted) Medication Review GP / Pharmacist Vaccinations Immunisation handbook: 4.7.7: persons at risk of complications from Influenza infection. Flu shot annually in March/April. Consider Pneumovax if appropriate. GP / Nurse Self Management Set achievable goals Sharing your care with your GP Ask the right questions Manage your chronic condition(s) Self management course Community chronic disease program http://www.kidney.org.au/ Chronic disease wellness program-Central intake unit ph: 1300 668 936 Patient to implement GP/Nurse to review (12 monthly review) Referral to education/self management group Support Kidney Health Information Service 1800 454 363 www.kidney.org.au Patient information and education Waist Circumference Current: BMI Current: Ideal weight should be BMI < 25 kg/m2 and waist circumference < 94 cm in men (< 90 cm in Asian men) or < 80 cm in women (including Asian women). 6. Medications 7. Self Management 8. Indications for Nephrologist referral eGFR < 30 mL/min/1.73m2 (Stage 4 or 5 CKD of any cause) Persistent significant albuminuria (urine ACR ≥30 mg/mmol) A sustained decrease in eGFR of 25% or more within 12 months OR a sustained decrease in eGFR of 15 mL/min/1.73m2 per year CKD with hypertension that is hard to get to target despite at least three anti-hypertensive agents Disclaimer: This template was developed from the resource www.kidney.org.au. It has been modified to local needs by GCPHN. It is up to each individual Doctor to ensure compliance with MBS guidelines. It is up to each Doctor to decide best practice care for each individual patient. Version: February 2016 The individual’s wishes and comorbidities should be taken into account when considering referral. Referral Triage Guidelines - Renal GCUH outpatients ph no: 1300 744 267 Recommended tests prior to referral: Current blood chemistry and haematology Urine ACR and urine microscopy for red cell morphology and casts Current and historical blood pressure Urinary tract ultrasound 9. Common CKD complications (more common once eGFR < 30 mL/min/1.73m 2) and other conditions Condition Target Acidosis Anaemia Supplementation with sodium bicarbonate Hb 100-115g/L Refer to CKD Management in General Practice (3rd edition) No lower than 0.75g/kg body weight per day Screen recurrently and maintain a high level of clinical awareness for depression. Modifiable causes of depression should be considered and excluded. Treatment with behavioural and pharmacological therapies Consider K10/DASS ATAPS Refer to Accredited Practicing Dietitian Healthy GC Dietitian List Depression Dietary protein Management Use dipsticks rather than urine microscopy as dipsticks are more Haematuria Hyperkalaemia Malnutrition Mineral and bone disorder Osteoporosis Muscle cramps K+<6.0 mmol/L Serum albumin >35g/L Keep PO4 in normal range (0.8-1.5 mmol/L) Keep Ca in normal range (2.2-2.6 mmol/L) Vitamin D (25-hydroxyvitamin D) levels are adequate if > 50 nmol/L Refer to Nephrologist if PTH is persistently elevated above the upper limit of normal and rising sensitive and accurate. Evaluate further if there is a result of 1+ or more. Do not use urine microscopy to confirm a positive result. However, urine microscopy may be useful in distinguishing glomerular haematuria from other causes. Low K+ diet (discuss with an Accredited Practicing Dietitian) Correct metabolic acidosis (target serum HCO3 > 22 mmol/L) Potassium wasting diuretics (e.g., thiazides) Avoid salt substitutes which may be high in K+ Resonium A powder Cease ACE inhibitor/ARB/spironolactone if K+ persistently > 6.0 mmol/L and not responsive to above therapies Refer to nearest Emergency Department if K+ > 6.5 mmol/L Refer to Accredited Practicing Dietitian What to measure Calcium & phosphate PTH & alkaline phosphatase* 25hydroxyvitamin D GFR 45-59 mL/min/1.73m2 6-12 months GFR < 45 mL/min/1.73m2 3-6 months Baseline 6-12 months Baseline Baseline Consider BMD Encourage stretching and massaging of the affected area Tonic water can be effective for frequent cramps Disclaimer: This template was developed from the resource www.kidney.org.au. It has been modified to local needs by GCPHN. It is up to each individual Doctor to ensure compliance with MBS guidelines. It is up to each Doctor to decide best practice care for each individual patient. Version: February 2016 Pruritus Ensure that there are no other causes for pruritis (e.g., allergies, scabies, inadequate dialysis, calcium/phosphate) Evening Primrose Oil Skin emollients Avoid use of soaps/detergents Topical capsaicin (may not be tolerated because of transient burning feeling on the skin) If both pruritis and restless legs is present, consider gabapentin For persistent pruritis, consider referral to a dermatologist for ultraviolet light B (UVB) therapy Restless Legs Check iron status and replace if deficient Home therapies such as massage, warm baths, warm/cool compresses, relaxation techniques, exercise Dopaminergic agents or dopamine agonists Benzodiazepines Weight reduction (see page xx lifestyle modification) Avoid central nervous system depressants (including alcohol) CPAP therapy (if obstructive pattern) Dialysis should be commenced as soon as uraemic symptoms Sleep Apnoea Uraemia develop Diabetes Monitoring of blood glucose and 3-6 monthly HbA1c test. Early intervention with infection Optimal blood glucose control Recurrent infection T.C.A AHP Type Reason Name No. of EPC visits 5 in total/calendar yr Agreed to TCA Yes/No Summary of Actions Required: Review Date with GP: I have explained the steps and any costs involved, and the patient has agreed to proceed with the plan. <<Steps and costs explained, patient agreed>> GP’s Signature: x_________________________ Date: <<Miscellaneous: Date>> GP Name: <<Doctor: Name>> I have agreed / my carer has agreed to this management plan and I understand the recommendations. Signed by Patient / Carer / or verbal: x_____________________________ Date: <<Miscellaneous: Date>> Disclaimer: This template was developed from the resource www.kidney.org.au. It has been modified to local needs by GCPHN. It is up to each individual Doctor to ensure compliance with MBS guidelines. It is up to each Doctor to decide best practice care for each individual patient. Version: February 2016