Nephrology Directorate Aintree Kidney Patient Care Plan Peritoneal Dialysis (PD) Please bring this Care Plan with you to wherever you visit: whether to the surgery, in the hospital or on holiday. This will make the health team aware about your health problems and your Medications. You or a member of your health team can update your care plan after each visit with any changes in your care. You must update your Medications list Immediately if any changes are made. Name of Lead for care plans: Dr Bhavna Pandya, Consultant Nephrologist, Aintree University Hospitals.
CARE PLANNING is about addressing an individual s full range of needs delivered by primary care, hospital, community and social health care professionals, to provide holistic approach to empower and self manage his or her care. Care plan is a document containing individual s health problems, medications list, treatment plans and contact numbers. You have been given your care plan book at reception. If you already have one please return it back to reception. Please give your care plan book to the clinician when you see them. They will complete the relevant pages at your first visit. HOW TO USE your care plan book: The information below will guide you about each page and how it can be filled in. Front page: General info about care plan Page 2: Your details- please complete your address details and the phone no, while you wait to see the clinician. Consultant details will be filled in by clinician at bottom of page. Page 3: - Details of your diagnosis will be filled in by your clinician. In the remaining space available any future new diagnosis can be added on. Page 4:- Vaccinations- please contact your surgery or nurse practitioner for details to fill that section in. We will update your immunity results for you when available Page 5: Contains some definitions and explains some of the terminology used on this book. Page 6: -Lists the patient information leaflets and the date they are discussed or given out. You or your clinician can tick and put the appropriate date as received. Page 7-10: Please list the medications and dose. Please make sure you update this regularly for any changes made at GP Surgery and/or Hospital. Page 11: Please record your blood pressure and the date each time you check. Usually pre & post PD. Page12: Record of your weight and the date when relevant. Page 13- Some definitions and explanations of your relevant kidney blood tests. Page 14: Know your numbers- the results can be recorded by yourself or your clinician. 2 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Page 15: Treatment options. To be completed by your clinician when discussions and decisions are made for transplant, dialysis or non- dialysis treatment when relevant. Page 16: This is your diary where you can fill in your appointment dates. Page 17: Some contact details of our department. Page 18: General information sites including any patient support groups. Page 19-20: You can request your clinician or nurse to summarise the plans when you get discharge from hospital. Page 21-26: These pages are for you or your health team to fill in according to agreed targets and objective plans including advance care planning when relevant. Page 27: You can request other health professionals to add their comments when you visit their appointments for better communication. Page 28-29: These pages are designed to write down the points regarding any questions or queries you may have and want to ask your health team. Patient Details UNIT NUMBER NAME DOB ADDRESS TELEPHONE NUMBER My blood group is My GP Name and address 3 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
CONSULTANT: TEAM 1 Dr Abraham, Dr Wong, Dr Goldsmith Team 2 Dr Pandya, Dr Chandrasekar, Dr Sharma POSSIBLE DIAGNOSIS OTHER DIAGNOSES 4 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Vaccinations FLU s: ; ; ; ; ; ; PNEUMOVAX s: ; HEPATITIS B VACCINE COURSE: s and Dose: 1 Dose 2 Dose 3 Dose Hep B Antibody check Booster date Titre 5 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Definitions and meanings Here is some brief information regarding some of the terminology you will come across during the course of your illness as a kidney patient on Peritoneal Dialysis (PD). The detailed information is available in an individual leaflet. Working Kidneys purify blood by throwing out toxins via urine while retaining blood, protein and other important substances in body tablets. Renal Patient View (RPV) provides online information about renal patients' diagnosis, treatment, and their latest test results. Patients can share this information with anyone they want, and view it from anywhere in the world. Peritoneal Dialysis (PD) is carried out via fluid introduced into the abdomen, then drained out using a Cannula or Catheter (tube). PD is a dialysis technique that uses the patient's own body tissues inside the abdominal cavity (Peritoneum) as a filter. This can be done either manually or by a machine at home, thereby avoiding hospital dialysis. Anaemia means there are not enough red blood cells in your blood. This is measured as haemoglobin (Hb). In kidney patients a substance called erythropoietin which helps in the formation of red blood cells is produced less by the kidneys. CRP: (CRP) levels increase during peritonitis which is a potentially fatal inflammation of the abdomen's lining. You will have CRP measured with your other monthly bloods. Strict hand hygiene is paramount when undergoing PD. You will be taught what signs to look for by your Nurse. Albumin: is a protein in the blood. It will be low if you are unwell or unable to eat properly. Your Dietician will help you understand your dietary needs. Calcium & Phosphate: Kidneys produce vitamin D which helps body to maintain calcium and phosphorous - substances to keep bones and your vessels healthy. If these minerals are too high or low they can be dangerous. Transplant of a Kidney from another individual is considered when the kidneys do not function. A Family member or Friend can volunteer to do this for you at any time. You will have routine Transplant bloods taken in January, April, July & October. 6 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Patient Information Leaflets Topic Leaflet given Discussion Renal Patient View (RPV) General Info + Chronic Kidney Disease (CKD) Know Your Numbers You and Your Medicines Anaemia Erythropoietin therapy Calcium and Bone Chemistry Haemodialysis / Peritoneal dialysis/conservative (Nondialysis) therapy CKD Stage V treatment options Vascular access Transplant Patient Decision Aid (PDA) Concise guide Full guide Kidney Biopsy Stop Gap Potassium Dietetic leaflets (From Dietitian) 1. 2. 3. 4. Planning for your future care [Advance Care Planning (ACP)] Please ask any questions regarding information given in this booklet or any other subject to the doctor/nurse in clinic. This will help you understand your treatment plan. Some of the information in this care plan may not be relevant to you. Please remember that each patient with kidney disease will have different problems and treatment plans. 7 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Please keep your MEDICINES record up to date by asking the doctor / nurse to fill in the list IF they make any changes to any drug. Allergies: Drug Name Dose Frequency For Hospital Use changed Reason or stopped Aranesp Venofer / Cosmofer Dose Freq. Dose 8 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Drugs to avoid: Drug Name Dose Frequency For Hospital Use changed Reason or stopped Aranesp Venofer / Cosmofer Dose Freq. Dose Freq. 9 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Drug Name Dose Frequency For Hospital Use changed Reason or stopped Aranesp Venofer / Cosmofer Dose Freq. Dose Freq. 10 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Drug Name Dose Frequency For Hospital Use changed Reason or stopped Aranesp Venofer / Cosmofer Dose Freq. Dose Freq. 11 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Blood Pressure Record BP BP BP Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Post Pre Pre Pre Post Post 12 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Weight (Kg) Record Dry Weight Dry Weight Dry Weight Weight Weight Weight PRE PRE PRE post post post post post post post post post post post post post post post post post post post post post post post post post Post post 13 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
KNOW YOUR NUMBERS Brief information (The details given below is only brief for your basic knowledge and does not include all the points. The detailed information is available in relevant leaflets. Please ask your Doctor or Nurse if necessary) Adequacy Clearance in Peritoneal Dialysis (PD) is typically measured by either Kt/V (Clearance, time and volume) or creatinine clearance (CrCl). Potassium is a substance which we consume in our diet accumulates in the body when kidneys functions are significantly reduced. Very high levels of potassium can cause various complications including sudden death. Bicarbonate is a measure of acid status in body. Kidneys produce bicarbonate to titrate acid produced normally in body. Bicarbonate level is reduced when kidney function deteriorates. PTH (Parathyroid Hormone): This hormone mainly maintains body s calcium and phosphate balance. The levels increase in response to low calcium and high phosphate in body. Increased PTH levels make bones brittle and arteries thickened. PET Test: (Peritoneal Equilibrium Test) can suggest how long PD fluid should stay (dwell) in your abdominal cavity for the best results. A PET will show if your peritoneum has a high, average, or low transport rate. The test looks at your drain volume, how much dextrose is left in the fluid sample, and how much creatinine is in your drain fluid vs. your blood. Your Nurse will explain what this means to you. Peritonitis: is an infection and inflammation of the Peritoneum. At best this is unpleasant and can be life threatening. Hand hygiene is essential when handling your PD Cannula. Your Nurses will educate you on this & how to be alert to the signs of infection. 14 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
KNOW YOUR NUMBERS Test Adequacy *(CrCl>50L /wk/1.73m2, KT/V>1.7) Potassium * (3.5-5.9 mmol/l) Bicarbonate *(22-30) PET (Peritoneal Equilibrium Test) CRP ( 0-10 ) Test Calcium (2.18-2.62 mmol/l) Phosphate (0.7-1.6 mmol/l) PTH (<1.3-6.8 pmol/l) Haemoglobin *(105-120 g/l) Albumin (35-50) Note-The values *(in bracket) suggest accepted range for CKD patients as per Renal Association UK guidelines. +The value indicates normal laboratory range only and significance varies with egfr value. 15 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Renal Replacement Therapy (RRT) TRANSPLANTATION Suitable for transplant list Y / N Reason listed Previous transplants details: Previous PD: yes/no s: ; Details: Previous peritonitis Previous exit site infection s Details s Details Previous HD: yes/no s: ; Previous vascular access details: PD cannula insertion date: / / Medical/Surgical: commenced PD: PD regime:apd/capd 16 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
APPOINTMENTS Next Appointments OPD/ Ward review/ Blood tests DATE OPD/ Ward review/ Blood tests DATE 17 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Discharge Plans Plans (Please call ward 20 for any out of hours emergencies or in case you are getting admitted to AED) 18 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Discharge Plans Plans 19 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
My Personal Health Plan The points below are the examples that you and your health care professional might want discuss for your care planning. There are blank areas in the next table for you to include the points important for you and not already listed. Health related issues or concerns: Non-Health related issues or concerns: Multi-Disciplinary team input Any other issues or concerns Results Treatment information Treatment choices: Transplant, Dialysis, No-dialysis therapy My kidney disease Changing my treatment My other health concerns Changing dialysis modality Stopping dialysis or any other Holidays Money or benefits Work or study related issues Food or drink Exercise or fitness activity related Other Dietician Social worker Physiotherapy Other teams: Radiology Clinical Psychology
: Team/professional Goal (How would I like things to be different) Targets (Where do I want to be?) Plans (My care team to do) Plans (What do I need to do?) Care Planning Targets and Objectives Difficulties To achieve by (date) Achieved (date) 21 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Care Planning Targets and Objectives : Team/professional Goal (How would I like things to be different) Targets (Where do I want to be?) Plans (My care team to do) Plans (What do I need to do?) Difficulties To achieve by (date) Achieved (date) 22 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Care Planning Targets and Objectives : Team/professional Goal (How would I like things to be different) Targets (Where do I want to be?) Plans (My care team to do) Plans (What do I need to do?) Difficulties To achieve by (date) Achieved (date) 23 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Care Planning Targets and Objectives : Team/professional Goal (How would I like things to be different) Targets (Where do I want to be?) Plans (My care team to do) Plans (What do I need to do?) Difficulties To achieve by (date) Achieved (date) 24 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Planning for My Future Care [Advance Care Planning (ACP)] Initial ACP discussion Written information given Completed ACP Review of ACP 1. 2. 3. 4. 5. By My personal Plan (Points I would like my care team to be aware of about me): 25 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Multidisciplinary notes Other (non-renal) team comments Signature 26 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Any other issues for discussion Issue or concern if resolved Holidays Work or study 27 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
Notes 28 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
CONTACT TELEPHONE NUMBERS Dr PANDYA/Dr ABRAHAM S SECRETARY 529 8796 Dr WONG S / Dr GOLDSMITH S SEC 529 3356 Dr CHANDRASEKAR/Dr SHARMA S SEC 529 8797 SOUTHPORT NEPHROLOGY SEC 01704 704 569 WARD 20 & DIALYSIS UNIT 529 8825/3814/3529 WARD 20 PCU (programmed Care Unit) 529 4011 AINTREE FRESENIUS DIALYSIS UNIT 529 8802 WATERLOO DIALYSIS UNIT 920 4280 SOUTHPORT DIALYSIS UNIT 01704 518 980 HOME DIALYSIS NURSES 01515293464 07966882953/07891645444 ANAEMIA AND VASCULAR ACCESS NURSE Sojan Thomas 0151 529 6405, BLEEP-5364 INTERVENTIONAL RADIOLOGY 529 2368 Fax No.s : Aintree- 0151 529 2420, Southport- 01704 704 787 Please contact your renal team member for any cultural issues.the issues related to faith or language or any other issues. 29 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya
FURTHER INFORMATION WWW.AINTREERENALUNIT.NHS.UK (website for Aintree Kidney Unit) AINTREE KIDNEY PATIENT ASSOCIATION (AKPA) (www.aintreekidneypatientsassociation.org.uk ) Contact Secretary to Dr Pandya 0151 529 8796 SOUTHPORT KIDNEY FUND ( http://southportkidneyfund.org/wp/ ) Mrs. P. Carr 01704 220951 Mrs. J. Coleman 01704 560824 MERSEY KIDNEY PATIENTS GROUP www.merseykidney.org WWW.KIDNEY.ORG. (NKF - National Kidney Federation) WWW.MERSEYRENALUNITS.NHS.UK (website for all Mersey renal units) www.renalpatientview.org 30 Aintree renal patient care plan January 2013. Lead: Dr B K Pandya