Coronary Heart Disease (CHD)

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Coronary Heart Disease (CHD)
A Nurses Perspective

• Gloria Clayton

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STATISTICS OF CHRONIC DISEASE

• More than 70 of Australias 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.

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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

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LIFESTYLE ACTIVITIES RETARDING HEALTH

• Smoking
• Nutrition-poor or incorrect diet
• Alcohol
• Physical inactivity
• Weight in excess
• Elevated Blood Pressure
• Elevated cholesterol

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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.

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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 GPMPs 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.

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PLANNING THE CLINIC

• Desired
• Protected time, apart from routine nursing
  duties. Negotiated with Practice Manager or GP.
• Good receptionist who knows the system, for
  recall protocol, who knows about billing, TCAs,
  EPCs and then gives out questionnaires e.g.
  mood tools, medication and activity enquiries.

Equipment PC with electronic medical record
access Blood Pressure Monitor (large small
cuffs should be available) Scales Tape Measure
(large) Foot care filaments Check lists
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.
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RUNNING THE CLINIC

• Yearly Dopplers for PVD/Diabetes patients.
• Yearly ECG for CHD pts and depending on MO for
  Diabetics as well.
• Foot check. Examination of feet noting toenails,
  callus, sensation skin colour. Done 6 monthly.
  (Use Nylon monofilament no 4)
• Notation of last eye check, allied health
  specialists.
• Lifestyle checklist- encourage patient in regards
  setting own goals e.g. exercise diet, with help
  of a registered nurse.
• Recall and review dates- Appointment made by RN.
  3 months if high risk, recent cardiac event,
  medication changes, off target or depressed.) Low
  risk 6mths.
• Hand out relevant literature.

• Initial clinic appointment 45 mins. Follow ups 15
  mins. Annual check 45 mins.
• Explain Role of Registered Nurse.
• Check Depression/Anxiety score
• Explain Investigation Results
• Check pathology results e.g. E.LFTs Cholesterol
  Glucose TFTs yrly if on Thyroxine. Digoxin
  trough if on Digoxin. (Collected 6hrs post last
  dose, or pre next dose.)
• Measurements weight, height, waist Blood
  Pressure

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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
  TCAs or EPCs if necessary and phone.

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CYCLE OF CARE
Cholesterol should be as low as possible.
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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.

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WORDS OF WISDOM
positive thinking
encourage points to drive health management
encouraging self belief in results
don't be a bully
provide opportunity for contact and encouragement
by using P/N's as tools
be cheerful
Keep a health diary
Avoid taking patients problems on board
personally. Concentrate on positives. Remember
future chances exist to make a difference if
rapport established.
don't keep it a secret
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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, GPs in
  other areas find GPMPs 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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THE END!!!!!!!!!!!!!