Asthma Assessment & Review

Transcription

1 ASTHMA RESOURCE PACK Section 5B Asthma Assessment & Review In this section: 1. Primary Care initial assessment and review Asthma Resource Pack Section 5B: Asthma Assessment & Review Version 3.0 Last Updated: June 2015

2 1. PRIMARY CARE INITIAL ASSESSMENT AND REVIEW The following templates can be used to support comprehensive asthma management and recommend that these questions be asked at assessment and each review, enabling comparison with previous reviews. The forms are designed to enable data / information capture which will support the clinician to gather a complete history and thereby support a focused discussion. We would recommend that you adapt the pages within your computer system where possible to take account of the recommended structured review process. We would welcome your feedback on this and any suggestions. Page 2 of 7

3 NHS Fife Guideline for the Management of Asthma Initial Assessment and Diagnosis of Asthma Summary of Initial Assessment Form Patient Details Personal details Occupation Pets Exercise tolerance grade Smoking status Present Symptoms Wheeze, shortness of breath, exercise intolerance, chest tightness, cough, nocturnal symptoms Episodic or persistent Time off work/education in the past year Number of puffs of β 2 agonist daily (if applicable) Trigger Factors URTI, Exercise, Stress, Tobacco, Smoke, Dust, Pollen, Animals, Food, NSAID, Aspirin, Other Medication, Cold Air, Chemicals/irritants/aerosols Relevant atopic history e.g. nasal polyps, hayfever, eczema Family History Relevant Past Medical History Current Medication Examination Height, Weight, Blood pressure, BMI PFR (Predicted and Actual) Date of last chest x-ray and result (if applicable) Inhaler technique (if applicable) Details of contra-indicated drugs Record method of confirmation of diagnosis Chest examination Checklist Explain diagnosis and assess understanding of asthma Give supporting information and signpost to Commence treatment plan as appropriate Discuss trigger factors and their avoidance Does the patient have a peak flow meter and can they use it competently? Agree and give personal asthma plan Arrange follow-up appointment Page 3 of 7

4 Initial Assessment and Diagnosis of Asthma (Primary Care) [page 1] Date../../.. GP. Patient details Name DOB../../. Gender M F Occupation If considering diagnosis of occupational asthma, refer to Respiratory Physician Exposed to: Dust/Chemicals? Yes No Any better? (e.g. away from work, on holiday) Yes No Not Sure.. Pets? Yes No Exercise tolerance Grade: (see classification on page 2 overleaf) Smoking Status: Never Smoked Ex-smoker No. of years smoking... Current Smoker No. per day Smoking Cessation Advice Given Yes No Passive Smoking? Yes No If yes, Home Work other (e.g. child care) Present Symptoms Wheeze S.O.B Chest Tightness Cough Nocturnal Symptoms Exercise Intolerance Nasal symptoms.. Date of Onset:../../.. Episodic Persistent Time off work/education in past year () Puffs of β 2 agonist daily not applicable Pre-exercise β 2 agonist Yes No Trigger factors and their avoidance discussed: Yes No Aggravating factors: URTI Exercise Stress Tobacco Smoke Dust Pollen Animals Food Other Medication Cold air NSAID Aspirin Chemicals/irritants/aerosols Atopic History: Eczema Hayfever Nasal Polyps Rhinitis Conjunctivitis Other (e.g. food) History Family History of asthma/atopy Yes No Childhood symptoms (if adult) Yes No Relevant Past Medical History Page 4 of 7

5 Initial Assessment and Diagnosis of Asthma (Primary Care) cont. [page 2] Current Medication Drug Strength Dosage Device *Ensure any prescribed inhaled corticosteroid dose and preparation are licensed for this person i.e. according to age. Step down gradually if not under regular review by Secondary Care Consultant. Examination Height: Weight: BP: / BMI: Date of last chest X-Ray../../.. Result Spirometry: FEV1..(% pred..) FVC.(% pred.) FEV1/FVC Expected PFR: Actual PFR: (% pred) Present inhaler device Present inhaler technique: Satisfactory Unsatisfactory Present level of understanding of asthma: Satisfactory Incomplete Information given/accessed: Information Leaflets Websites Diagnosis Confirmed by: History Follow-up Appointment Y N Wheeze Response to treatment Objective Measurement (See below) Drugs which may cause bronchoconstriction / bronchospasm? Β Blocker Y N Aspirin Y N NSAIDs Y N Other(s) Y N. Peak Flow Meter (has own device) Y N Personal Asthma Plan agreed? Y N Users Peak Flow Meter competently Y N Personal Asthma Plan given? Y N Main carer (if applicable) Others who need to know about asthma and its management... Objective Diagnosis Measurements Serial Peak Expiratory Rate 1. >20% diurnal variation on 3 in a week for 2 weeks on PEF diary twice daily (4times may be more sensitive) OR Positive Reversibility Test Salbutamol 2. FEV 1 15% (and 200ml) increase after short acting β 2 agonist e.g. Salbutamol 400mcg by MDI and Spacer or 2.5mg by Nebuliser OR Spirometry Reversibility Positive 3. FEV 1 15% (and 200ml) increase adter trial of beclamethasone 200mg (or equivalent) twice daily Exercise Tolerance Grading Criteria Grade 1: Asthma but with no limitation of physical activity Grade 2: Asthma with slight limitation of physical activity but by limiting physical activity, can lead a normal social life. Grade 3: Asthma resulting in marked limitation of physical activity. Grade 4: Asthma resulting in being unable to do any physical activity without shortness of breath. Page 5 of 7

6 Asthma Review (Primary Care) [page1] Name: DOB:../../.. FOLLOW-UP:.../. /...././...././. For children read you as the child Symptoms Do you cough, wheeze or get short of breath? Y N Y N Y N In the last month: 1. Have you had difficulty sleeping because of your Asthma symptoms (including cough)? 2. Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? 3. Has your asthma interfered with your usual activities (e.g. housework, school/work, etc)? 4. Have you had Nasal Symptoms (eg sneezing, runny nose, blocked/sniffing, itchy) Y N Y N * Y N Y N nights Y N * Y N Y N Y N * Y N Y N nights Y N * Y N Y N Y N * Y N Y N nights Y N * Y N Yes/No Yes/No Yes/No PEFR Predicted Best Actual Trigger factors and their avoidance discussed* No. of unscheduled asthma appointments Current Asthma Medication.. Y N Action.. Y N Action... Y N Action (Ensure any prescribed inhaled corticosteroid dose and preparation are licensed for this person i.e. according to age. Step down gradually if not under regular review by Secondary Care Consultant.) No. of puffs of β 2 agonist daily No. of short courses of oral steroids since last review Other medication including over the counter Changes in Asthma medication including over the counter Page 6 of 7

7 Asthma Follow-up [page2] Name: DoB:../../.. DATE:../../..../../..../../.. Inhaler technique Assessment Result Assessment Result Assessment Result Satisfactory Unsatisfactory Satisfactory Unsatisfactory Satisfactory Unsatisfactory Action Action Action Steroid Adverse Effects Testing (For further information please refer to 5.6 for Children or 6.6 for Adults) Y N N/A Y N N/A Y N N/A Weight/Height (Annually < 18yrs) Kg m Kg m Kg m Asthma education / concordance discussed Y N Y N Y N Asthma literature offered Written Personal Asthma Plan Reviewed /Given? Record the date the plan was last updated Y N Y N Y N Y N Y N Y N Action Action Action Advised to inform school of plan given / changed Flu Vaccination Pneumoccoccal Vaccination Smoking status (include passive smoking) Smoking Cessation Advice Given Pregnant Y N N/A Y N N/A Y N N/A Date:././. Date:././. Date:././. Date:././. Date:././. Date:././ Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A Planning Pregnancy Y N N/A Y N N/A Y N N/A Personal worries/ concerns Is there anything you avoid due to your asthma? Next Appointment: Nurse / GP / Hospital** Y N Y N.. N GP H Date:././. Y N Y N.. N GP H Date:././. Y N Y N.. N GP H Date:././. ** If patient is attending for a paediatric hospital review, please copy and send this completed form to: Anne McKean (Paediatric Asthma Specialist Nurse, VHK) Reproduced with thanks to Forthvalley Airways MCN Page 7 of 7