pPCI CARDIAC REHABILITATION ASSESSMENT
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pPCI CARDIAC REHABILITATION ASSESSMENT PATIENT DETAILS DOB: GP DETAILS Unit No.: Likes to be called: ......................................... GP Tel No: ............................................................. Tel No’s: ......................................................... Communication issues: ....................................... .......................................................................... ................................................................................ .......................................................................... Religion: ................................................................ M/F Referral Date: ........................................................ Age: ......................... Invited for Rehab: ................................................. NOK Details Rehab Started: ...................................................... Name: .............................................................. Consent Given: YES / NO Relation: ......................................................... Ethnicity: White / Black / African / Chinese / Tel No: ............................................................ Black Caribbean / Bangladeshi / Indian / Other: Referral Source: Consultant / Nurse ............../ GP / Other (please state): .................................... Assessed By: ME / LS / CS / AS / CH ........................................................................................ EM / TC / HN / MM / KB / TO / RW / HH ............................................................. Datacam: Admission Date In pt Initiating Event CRass Trop Initiating Treatment Phase 4 / Discharge Date Consultant Discharge Date Admission Details: ...................................................................................................................................... ...................................................................................................................................................................... ...................................................................................................................................................................... ...................................................................................................................................................................... ...................................................................................................................................................................... ...................................................................................................................................................................... CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 1 of 14 CARDIAC / VASCULAR MEDICAL HISTORY TYPE DATE DETAILS TYPE DATE MI Angina Surgery ACS PTCA CABG Arrest Valve Surgery Heart Failure Pacemaker Transplant ICD Congenital LV Assist PVD TIA CVA Other DETAILS NONE GENERAL PAST MEDICAL HISTORY DETAILS DETAILS Arthritis / Osteoarthritis Rheumatism Cancer Back Problems Asthma Osteoporosis Bronchitis AIDS/HIV Emphysema Claudication Diabetes Other co-morbid Complaints Details: CORONARY HEART DISEASE RISK FACTOR PROFILE CRF v4.5Pathway Oct2011 Hypertension Hyperlipidaemia Smoking Diabetes Family History Overweight Excess Alcohol Low Levels of Activity Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 2 of 14 SOCIAL CIRCUMSTANCES Marital Status: Single / Married / Permanent Partner / Divorced / Widowed Accommodation: House / Flat / Bungalow / Sheltered / Warden Controlled / Boat / Caravan / Nursing Home / Other .......................................................................... Patient Lives With: Partner / Spouse / Alone / Relative / Dependants / Other ...................... Details/Concerns .................................................................................................................. Working Status: Full Time / Part Time / Retired / Self-employed / Unemployed / Disabled / Looking for Work / Permanently Sick / Temporarily Sick / Student / Gov. Training Scheme / Looks after Family / Other ................................ Job Title: .................................................................................................................. Social Economic Group: I / II / IIIM / IIIN / IV / V INITIAL ASSESSMENT Driving Regulations Explained: Y / N / NA .................................................... Rules of Chest Pain Discussed: Y/N .................................................... When to call 999: Y/N .................................................... Cardiac Rehab Info Booklet Provided: Y/N .................................................... INVESTIGATIONS/TESTS Test Date Comments ....................................................................... Echo: ....................................................................... ....................................................................... ETT: Rhythm ECG: Rhythm APPOINTMENTS Date Details CRASS Rehabilitation Appointments Exercise Start Graduation Medical Appointments Cardiac Investigations CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 3 of 14 NAME DESIGNATION MARION ELLIOT Senior Nurse TRISH OSBALDESTON Cardiac Rehabilitation Nurse TESSA COBB Cardiac Rehabilitation Nurse HELEN NOLTE Cardiac Rehabilitation Nurse MIRANDA MOWBRAY Cardiac Rehabilitation Nurse KATE BLAYNEY Cardiac Rehabilitation Nurse EMMA MILLS Cardiac Rehabilitation Nurse RACHAEL WALKER Cardiac Rehabilitation Nurse SIGNATURE DATE Cardiac Rehabilitation Nurse HANNAH HINDMARSH Exercise Physiologist Exercise Physiologist LYNN SCHOFIELD Clinical Nurse Specialist CAROL SCHOFIELD Cardiac Rehabilitation Nurse ALEX SMITH Cardiac Rehabilitation Nurse CATH HAWLEY Cardiac Rehabilitation Nurse Exercise Physiologist CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 4 of 14 MEDICATION RECORD Known Allergies:- ................................................................................................ DATE DATE DATE DATE Name & Dose Name & Dose Name & Dose Name & Dose DRUG GROUP Beta Blockers Bisoprolol ...... mg Bisoprolol ....... mg Bisoprolol ....... mg Bisoprolol ...... mg Atenolol ...... mg Atenolol ....... mg Atenolol ....... mg Atenolol ...... mg Ramipril ...... mg Ramipril ....... mg Ramipril ....... mg Ramipril ...... mg ACE Inhibitor A2 Antagonist Statin / Fibrates Atorvastatin ..... mg Atorvastatin ...... mg Atorvastatin ...... mg Atorvastatin ..... mg Simvastatin ...... mg Simvastatin ...... mg Simvastatin ...... mg Simvastatin ...... mg 75 mg 75 mg 75 mg 75 mg Aspirin Other Anti-Platelets Digoxin Prasugrel Prasugrel Prasugrel Prasugrel Clopidogrel 75 mg Clopidogrel 75 mg Clopidogrel 75 mg Clopidogrel 75 mg ..................mcg .................. mcg .................. mcg .................. mcg Diuretics Nitrate GTN Spray/Tabs Pre-admission Medies CRF v4.5Pathway Oct2011 Others:- Oxford University Hospitals NHS Trust Others:- To be Reviewed Oct 2012 Others:- Others:- 5 of 14 IN PATIENT ASSESSMENT pPCI FOLLOW UP CLINIC Date: Date: Chest Pain / Wound Pain / Heart Failure CCS 0 / I / II / III / IV Chest Pain / Wound Pain / Heart Failure Since previous F/U: Y / N CCS 0 / I / II / III / IV Details: ..................................................................... Details:..................................................................... .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. Has GTN: Y/N Aware of Rules of Chest Pain: Y/N Reported Side Effects of Medication: Y / N Explanation of Medications: Heart Failure Assessed Echo Performed Y/N Y/N Y/N Details:..................................................................... Comments: ............................................................... ................................................................................. .................................................................................. ................................................................................. ACTIVITY NYHA Class I / II / III / IV ACTIVITY NYHA Class I / II / III / IV Current Activity Levels 1: Per week how many times does pt. do Activity: Safe: Strenuous ............... Moderate ............ Mild ........... 2: Does Pt sweat during activity: Often Sometimes 3: Does pt. do 30 mins Activity 5 times per week: ................................................................................. ................................................................................. Never / Rarely ................................................................................. ................................................................................. Y/N Type of Activity: ........................................................ .................................................................................. Safe Levels of Activity Post Discharge Discussed: Y/N ................................................................................. ................................................................................. ................................................................................. ................................................................................. Y/N .................................................................................. Gym Start Date: ....................................................... .................................................................................. Driving Resumed: Y/N Interested in Exercise Sessions: Y/N SMOKING ASSESSED Never Type: SMOKING ASSESSED Y/N Current Ex-Smoker Cigarettes / Pipe / Rollups / Cigars Never Current Is Ex-Smoker of > 1 Month: Duration: ................................................................... Smoke Within 30 mins. of Waking: ..................Y / N Smoking Cessation support offered: ................Y / N Referred to PN ................................................... Advice Given: ........................................................... .................................................................................. .................................................................................. .................................................................................. Y/N Discussed Quit Attempt: .................................. Y / N Smoking Cessation support offered: ............... Y / N Referred to PN ................................................... Advice Given: .......................................................... ................................................................................. ................................................................................. ................................................................................. Quit Period: .............................................................. ................................................................................. Daily Consumption: .............. ................................................................................. CRF v4.5Pathway Oct2011 Weekly: .................. Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 6 of 14 CARDIAC REHABILITATION ASSESSMENT Date: END ASSESSMENT Date: Chest Pain / Wound Pain / Heart Failure Since previous F/U: Y / N CCS 0 / I / II / III / IV Chest Pain / Wound Pain / Heart Failure Since previous F/U: Y / N CCS 0 / I / II / III / IV Details: ..................................................................... .................................................................................. Details:..................................................................... ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. Has GTN: Aware of Rules of Chest Pain: Reported Side Effects of Medication: Heart Failure Assessed: Echo Performed: Has GTN: Aware of Rules of Chest Pain: Reported Side Effects of Medication: Heart Failure Assessed: Echo Performed: Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Comments: ............................................................... Comments: .............................................................. .................................................................................. ................................................................................. ACTIVITY NYHA Class I / II / III / IV 1: Per week how many times does pt. do Activity: 2: Does Pt sweat during activity: Sometimes 3: Does pt. do 30 mins Activity 5 times per week: NYHA Class I / II / III / IV 1: Per week how many times does pt. do Activity: Strenuous ............... Moderate ............ Mild ........... Often ACTIVITY Strenuous ............... Moderate ............ Mild ........... 2: Does Pt sweat during activity: Often Never / Rarely Sometimes 3: Does pt. do 30 mins Activity 5 times per week: Y/N Never / Rarely Y/N Type of Activity: ........................................................ Type of Activity: ....................................................... .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. Role of Exercise in Prevention of CHD Discussed: Y/N ................................................................................. SMOKING ASSESSED SMOKING ASSESSED Y/N ................................................................................. Never Current Is Ex-Smoker of > 1 Month: Y/N Never Current Is Ex-Smoker of > 1 Month: Discussed Quit Attempt: ...................................Y / N Discussed Quit Attempt: .................................. Y / N Smoking Cessation support offered: ................Y / N Smoking Cessation support offered: ............... Y / N Referred to PN Referred to PN Quit form sent Quit form sent Advice Given: ........................................................... Advice Given: .......................................................... .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 7 of 14 IN PATIENT ASSESSMENT pPCI FOLLOW UP CLINIC Date: Date: PSYCHOLOGICAL STATE ASSESSED Y/N HAD Score: ............................................................ Dartmouth Co-op: Y/N History of Anxiety and Depression Y/N Psychological support offered Y/N Concerns voiced:...................................................... .................................................................................. .................................................................................. .................................................................................. Sexual concerns assessed Sexual Counselling offered Y/N Y/N PSYCHOLOGICAL STATE ASSESSED HAD Score: ............................................................ Psychological support offered Y/N Referred for Psychological Counselling Y / N Comments: .............................................................. ................................................................................. ................................................................................. ................................................................................. ................................................................................. Sexual concerns assessed Sexual Counselling offered .................................................................................. Return to Work Discussed Y/N .................................................................................. .................................................................................. .................................................................................. Cholesterol Assessed Hx of Chol: Y/N Y/N Y/N ................................................................................. Return to Work Discussed Y/N ................................................................................. ................................................................................. ................................................................................. Interested in information sessions DIET/WEIGHT MANAGEMENT Y/N Y/N DIET/WEIGHT MANAGEMENT Y/N Previous Statin Y/N Date: ................................ Waist > Hip: Y/N T Chol: ............................. Benefits of Oily Fish HDL: ................................ Mentioned: ................................................................................. ................................................................................. Y/N ................................................................................. ................................................................................. LDL: ................................. ................................................................................. HDL R: ............................. ................................................................................. Trig: ................................. BMI Assessed: ................................................................................. ................................................................................. Y/N Height: .............. Weight: ............... BMI: ................ Comments: ............................................................... .................................................................................. .................................................................................. .................................................................................. .................................................................................. .................................................................................. ALCOHOL ASSESSED Y/N ................................................................................. ................................................................................. ................................................................................. ................................................................................. ................................................................................. ................................................................................. ................................................................................. ALCOHOL ASSESSED Y/N Units / Week: ................... Units / Week: .................. Advice Given: ........................................................... Advice Given: .......................................................... .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 8 of 14 CARDIAC REHABILITATION ASSESSMENT Date: PSYCHOLOGICAL STATE ASSESSED Y/N END ASSESSMENT Date: PSYCHOLOGICAL STATE ASSESSED Y/N HAD Score: ............................................................ HAD Score: ............................................................ Psychological support offered Y/N Referred for Psychological Counselling Y / N Psychological support offered Y/N Referred for Psychological Counselling Y / N Comments: ............................................................... Comments: .............................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. Sexual concerns assessed Sexual Counselling offered Sexual concerns assessed Sexual Counselling offered Y/N Y/N Y/N Y/N ................................................................................. .................................................................................. Return to Work Discussed: Y/N .................................................................................. Return to Work: Y/N Date ......................................................................... .................................................................................. Full time / Part time / Planned / Unplanned / Unemployed / Looking for work / Temporarily sick / Awaiting further investigation / HGV awaiting ETT . .................................................................................. ................................................................................. .................................................................................. ................................................................................. DIET/WEIGHT MANAGEMENT Cholesterol Assessed DIET/WEIGHT MANAGEMENT Cholesterol Assessed .................................................................................. Y/N Y/N Date: ................................ Waist > Hip: Y / N Date: ............................... Waist > Hip: Y / N T Chol: ............................. Benefits of Oily Fish T Chol: ............................ Benefits of Oily Fish HDL: ................................ Mentioned: Y / N HDL: ............................... Mentioned: Y / N LDL: ................................. LDL: ................................ HDL R: ............................. HDL R: ............................ Trig: ................................. Trig: ................................ BMI Assessed: Y/N BMI Assessed: Y/N Height: .............. Weight: ............... BMI: ................ Height: .............. Weight: ............... BMI: ................ Comments: ............................................................... Comments: .............................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ALCOHOL ASSESSED Y/N ALCOHOL ASSESSED Y/N Units / Week: ................... Units / Week: .................. Advice Given: ........................................................... Advice Given: .......................................................... .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 9 of 14 IN PATIENT ASSESSMENT pPCI FOLLOW UP CLINIC Date: Date: HYPERTENSION BP Assessed: Y/N HYPERTENSION BP Assessed: Y/N BP: .................... HR: ...................... Rhythm: ......... BP: .................... HR: ............ Rhythm: ................... Treated: Good Control: Salt Intake Discussed: ................................................................................. Y/N Y/N Y/N ................................................................................. ................................................................................. .................................................................................. .................................................................................. .................................................................................. .................................................................................. .................................................................................. .................................................................................. DIABETES Type I Type II Blood Sugars Assessed: Y/N ................................................................................. ................................................................................. ................................................................................. ................................................................................. ................................................................................. ................................................................................. DIABETES Blood Sugars Assessed: Y/N Range: ..................................................................... Diet Tabs Insulin Advice Given: .......................................................... ................................................................................. Inpatient Blood Sugar Range: .................................. HbA1C ...................................................................... Previous Control: ...................................................... Newly Diagnosed: Y/N .................................................................................. .................................................................................. .................................................................................. .................................................................................. Assessed: ................................................................................. ................................................................................. ................................................................................. Advice Given: ........................................................... FAMILY HISTORY ................................................................................. Y/N ................................................................................. ................................................................................. ................................................................................. HbA1C ..................................................................... Referred to PN / OCDEM: FAMILY HISTORY Y/N Assessed: Y/N Mother: ..................................................................... ................................................................................. Father: ...................................................................... ................................................................................. Siblings: .................................................................... ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 10 of 14 CARDIAC REHABILITATION ASSESSMENT Date: HYPERTENSION BP Assessed: Y/N BP: .................... HR: ............ Rhythm: ................... END ASSESSMENT Date: HYPERTENSION BP Assessed: Y/N Pre-Exercise BP: .................... HR: ............ Reg. / Irreg. .............. Good Control: Y/N Salt Intake Discussed: Y/N Post-Exercise Comments: ............................................................... BP: .................... HR: ............ Reg. / Irreg. .............. .................................................................................. Good Control: Y/N .................................................................................. Salt Intake Discussed: Y/N .................................................................................. Comments: .............................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. DIABETES Blood Sugars Assessed: Y/N DIABETES Blood Sugars Assessed: Y/N Result Date:.............................................................. Result Date: ............................................................. Blood Sugar Assessed: ..................... Random / Lab Blood Sugar: Assessed ..................... Random / Lab HBA1C: .................................................................... HBA1C:.................................................................... Effective Control: Effective Control: Y/N Y/N Advice Given: ........................................................... BM pre- Exercise: .................................................... .................................................................................. BM post-Exercise: ................................................... .................................................................................. Advice Given: .......................................................... .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. Referred to PN / OCDEM: Referred to PN / OCDEM: Y/N Attends Practice for Monitoring: Y / N FAMILY HISTORY Attends Practice for Monitoring: Y / N Assessed: Discuss with the Patient the Health of their Children : Y/N Y/N FAMILY HISTORY Assessed: Discuss with the Patient the Health of their Children : Y/N Y/N Y/N .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. .................................................................................. ................................................................................. CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 11 of 14 ATTENDANCE / APPOINTMENT INFORMATION NAME: .................................................................................................................................................. Patient has dates for the Information Sessions: Y/N Horton Information Sessions Week Topic Date 1 Healthy Eating 2 Understanding Heart Disease 3 Emergency First Aid 4 Pharmacist and Blood Pressure 5 Risk Factor Summary 6 Physical Activity and Heart Disease 7 An Introduction to Relaxation 8 Managing Day to Day Stresses JR Information Sessions Week Topic Date 1 Understanding Heart Disease Physical Activity Stress and Relaxation 2 Medications Healthy Eating and Food Labelling CBT CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 12 of 14 CARDIAC REHABILITATION EXERCISE ASSESSMENT NAME ............................................. AGE ...... EXERCISE START DATE ..................................... Grad Date ..................................... PROGRESS (since discharge – note any symptoms) If surgical 12 weeks since op: CURRENT PA (FITT) and advice given GTN On Person? Guidelines? Y Y Y N N N Y N PREVIOUS PA EXERCISE LIMITATIONS ADAPTIONS TO EXERCISE POSSIBLE MEDS SIDE EFFECTS / PA CONSIDERATIONS PATIENT CONCERNS PATIENT GOALS ADDITIONAL COMMENTS Actual / Predicted MRH ..................... RHR ................. TRH 40% ...................... 50% ................. RISK STRATIFICATION LOW 60% .............. MODERATE HRR ................... BB? 70% ................... 80% ................... HIGH Comments: Permission required Y N Permission received Y N CHECKLIST Discussed with Patient Up to 10 Weeks? Y N Effort score? Y N Sensible Precautions? Y N Safety advice? Y N Warm up / Cool down? Y N Exercise book given? Y N Home exercise? Y N EP INITIALS ........................ CRF v4.5Pathway Oct2011 SIGNATURE ............................................................. Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 DATE ............................ 13 of 14 SUPERVISED EXERCISE PROGRAMME Site: Horton / Abingdon / BBL / Witney Start Date: ................................................. Finish / Discharge Date: ......................................................... Graduated: If No reason for Discharge: .................................................... Y/N No. of Sessions Attended ........................ % of Gym Attendance ............................................................. Plan For Future Exercise Exercise Level Achieved: ......................... mins Phase IV Exercise HR Achieved: .............................bpm Exercise Referral Scheme Target HR: ................................................bpm Independent Gym Working at RPE: .................. (Borg 0-10 scale) Independent Exercise Limitations During Exercise: ............................ No Regular Exercise ............................................................................................................................................................ Referral Form Required: Y/N Referral Form Completed: ........................................ Sent To: .............................................................................................................................................. CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 14 of 14
