Scleroderma. My Individual Personal Care Plan. Rheumatology Department. Name: Date of Birth: Hospital No.: NHS No.:

Transcription

1 Rheumatology Department My Individual Personal Care Plan Scleroderma Name: Date of Birth: Hospital No.: NHS No.: Scleroderma Individual Personalised Care Plan

2 Proud to make a difference Living with Scleroderma is going to be part of your life, If you become involved in the day-to-day management of your health, you stand a better chance of maintaining the activities that fill your life. If you take on this job the same way you would take on a new career position, knowing it will require daily learning and practicing and that there will be setbacks as well as successes, you are on your way to managing your scleroderma. Knowing what you will physically be able to do tomorrow, next year, and beyond, starts with learning what Scleroderma is and what is happening inside your body. The next step is learning what you can do and what your limits are. The third step is forming and following a self-management plan for your life. Individual Personal Care Plan There are no rules around care plans - use them in whatever way is most useful to you. As a general guide:- 1. The personal profile is the first part to complete, gives you the advantage of only having to complete your general information once, regardless of how many care plans or long term conditions you have. 2. Identify and complete the plans relevant to you; work with your health care professional to complete the relevant sections, and understand the information contained within the plan. 3. Continually update your plan, and take it with you to any health appointments that you may have. Remember Care planning isn t just about filling in the form; it s much more than that and should help you to be actively involved in managing your own condition and influencing the care that you may receive. Scleroderma Individual Personalised Care Plan 2

3 Health Care Team: Contact Number: GP Consultant Rheumatologist Rheumatology Clinical Nurse Specialist Physiotherapist Occupational Therapist Community Matron Rheumatology Appointments District Nurse Other: Other: 3 Scleroderma Individual Personalised Care Plan

4 Appointments: Type of Scleroderma: Other Health Conditions: Scleroderma Individual Personalised Care Plan 4

5 Living with Scleroderma: Living well day to day with Scleroderma can be achieved by: Learning about your body and what is happening to it with Scleroderma. Learning about your health professionals, the recommended medications, and what they can do for you. Find out what can improve your health, such as losing weight or starting a flexibility exercise program. Learn how to cope with chronic pain, fatigue, and stiffness: Experiment and learn what can help you feel better and what makes things worse. Some people can write without pain while others can t, and the same goes for walking, aerobics, etc. Learn basic skills, such as ways to use your body that protect stiff areas, that will help you continue activities. Take an active role in managing your scleroderma: Gather information about Scleroderma and the steps you can take to stay active. Work with your team of health professionals, friends and family to set up a self-management plan. Set goals to practice your coping and strengthening skills and incorporate these goals into your life. Follow through with your self-management plan on a day-to-day basis. 5 Scleroderma Individual Personalised Care Plan

6 Preparing for your outpatient appointments: List of medication - remember to take a full list of your: Prescription Medication Over the Counter regular medication e.g. paracetamol etc. Herbal or complimentary medication e.g. devils claw etc. Know your allergies Have a list of your known allergies Urine sample Urinalysis is often used to monitor protein leakage and identify and assess urinary tract infections (UTIs). Most people with kidney problems will have an abnormal urinalysis. Protein, urine casts (especially red blood cell casts), red blood cells, or white blood cells in the urine can indicate serious kidney involvement; leukocyte esterase may indicate a bladder infection-collect the urine sample with 1-2 hours prior to your appointment. Questions Time with your Consultant, Doctor or Health Care Professional is often limited to 10 to 20 minutes. Ensure that you have a list of important questions you want to know the answer to. Blood Test Ensure that any blood tests are taken 5-7 days before your clinic appointment, If you live out of the area- ask your GP Practice for a copy of the blood tests results and bring them with you to the appointment. Other tests and Investigation - ensure that all tests and investigations requested from previous appointments are completed, let your Rheumatology department know well in advance if these have not be undertaken. New health problems Prepare a list of any new health problems you are being seen for- remember your clinical notes may not have all your up to date medical records, clinical letters etc. Scleroderma Individual Personalised Care Plan 6

7 Date: Patients comments, goals, questions and report impact on life: Consultation Records Treatment: Seen by: (circle) GP / Consultant/ SpR/ Specialist Nurse/Physio/OT/ Podiatrist Visual Analogue Scales (VAS): A good way of monitoring your pain and fatigue levels. To do this, simply decide on the number that best describes your level over the previous week and make a note of it on the chart on pages For example, if your pain levels were unbearable, level 10 would best describe that. Fatigue VAS: No fatigue Severe fatigue Referral: Outcomes & Advice: Investigations: Pain VAS: 0 1 No pain Digital/Non Digital Ulcers Yes/No Severe pain Follow up: If Yes, please indicate where: 7 Scleroderma Individual Personalised Care Plan

8 Date: Patients comments, goals, questions and report impact on life: Consultation Records Treatment: Seen by: (circle) GP / Consultant/ SpR/ Specialist Nurse/Physio/OT/ Podiatrist Visual Analogue Scales (VAS): A good way of monitoring your pain and fatigue levels. To do this, simply decide on the number that best describes your level over the previous week and make a note of it on the chart on pages For example, if your pain levels were unbearable, level 10 would best describe that. Fatigue VAS: No fatigue Severe fatigue Referral: Outcomes & Advice: Investigations: Pain VAS: 0 1 No pain Digital/Non Digital Ulcers present: Yes/No Severe pain Follow up: If Yes, please indicate where: Scleroderma Individual Personalised Care Plan 8

9 Date: Patients comments, goals, questions and report impact on life: Consultation Records Treatment: Seen by: (circle) GP / Consultant/ SpR/ Specialist Nurse/Physio/OT/ Podiatrist Visual Analogue Scales (VAS): A good way of monitoring your pain and fatigue levels. To do this, simply decide on the number that best describes your level over the previous week and make a note of it on the chart on pages For example, if your pain levels were unbearable, level 10 would best describe that. Fatigue VAS: No fatigue Severe fatigue Referral: Outcomes & Advice: Investigations: Pain VAS: 0 1 No pain Digital/Non Digital Ulcers Yes/No Severe pain Follow up: If Yes, please indicate where: 9 Scleroderma Individual Personalised Care Plan

10 Date: Patients comments, goals, questions and report impact on life: Consultation Records Treatment: Seen by: (circle) GP / Consultant/ SpR/ Specialist Nurse/Physio/OT/ Podiatrist Visual Analogue Scales (VAS): A good way of monitoring your pain and fatigue levels. To do this, simply decide on the number that best describes your level over the previous week and make a note of it on the chart on pages For example, if your pain levels were unbearable, level 10 would best describe that. Fatigue VAS: No fatigue Severe fatigue Referral: Outcomes & Advice: Investigations: Pain VAS: 0 1 No pain Digital/Non Digital Ulcers Yes/No Severe pain Follow up: If Yes, please indicate where: Scleroderma Individual Personalised Care Plan 10

11 Medication Record Rheumatology Outpatients Department Drug Date Dose Frequency Reason Prescribed by Prednisolone (Steroids) Disease Modifying Anti Rheumatoid Drug Important Notice Daily Do not miss a dose - any problems talk to your Rheumatology Team Slow Reduction as prescribed by your Rheumatologist Do Not Miss a Dose any problems talk to your Rheumatology team - Yearly flu Vaccination Required Comment Disease Modifying Anti Rheumatoid Drug Do Not Miss a Dose any problems talk to your Rheumatology team - Yearly flu Vaccination Required Scleroderma Individual Personalised Care Plan

12 Medication Record Date of last IIoprost infusion Drug Date started Please ensure that you have your bloods monitored every as directed by the Rheumatology Team Dose Frequency Reason Prescribed by Important Notice Comments Scleroderma Individual Personalised Care Plan 12

13 Blood Test Results Please ensure that you have your bloods monitored every... as directed by the Rheumatology Team Date HB WBC Platelets Neutrophils ESR CRP ALT Creatinine Urea Urinalysis Blood Pressure Weight 13 Scleroderma Individual Personalised Care Plan

14 Blood Test Results Please ensure that you have your bloods monitored every... as directed by the Rheumatology Team Date HB WBC Platelets Neutrophils ESR CRP ALT Creatinine Urea Urinalysis Blood Pressure Weight Scleroderma Individual Personalised Care Plan 14

15 Record of Additional Tests and Investigations Echo and Lung Function Test should be performed annually Date Investigation Result Outcome Echo Lung Function Test 15 Scleroderma Individual Personalised Care Plan

16 Type of Scleroderma: Serious complications of scleroderma are relatively rare, but regular check ups are recommended, so any problems can be identified and treated at an early stage. Serious complications may include:- Digital Ulcers The best way to treat digital ulcers is to prevent them from occurring in the first place. This is not easy but there are ways in which you may be able to minimise the risk- see Scleroderma Society and Raynaud s and Scleroderma Association patient information leaflets Report new vulnerable, ulcerations or discoloured areas to your Rheumatology Team Recognise symptoms of infectionincreased pain, swelling, redness, warmth, pus Comments Non-digital ulcers can also occur over pressure points such as joints e.g. elbows See Digital Ulcers in Connective Tissue disease leaflet Scleroderma Individual Personalised Care Plan 16

17 Type of Scleroderma: Serious complications of scleroderma are relatively rare, but regular check ups are recommended, so any problems can be identified and treated at an early stage. Serious complications may include:- Lung problems Report any signs of shortness of breath or dry ongoing cough (Lung Fibrosis) or symptoms of ankle swelling, fainting, or chest pain (Pulmonary hypertension) Comments Contact your Rheumatology Department if any of these symptoms occur Heart problems Patients with systemic sclerosis should undergo very detailed investigation where any symptoms of heart disease exist (breathlessness, chest discomfort, altered consciousness, palpitations, ankle swelling) because heart disease is common in systemic sclerosis and may be difficult to diagnose. Yearly monitoring for rare complications is important and an annual Echocardiogram and Lung Function Test is recommended Comments Contact your Rheumatology Department if any of these symptoms occur 17 Scleroderma Individual Personalised Care Plan

18 Type of Scleroderma: Serious complications of scleroderma are relatively rare, but regular check ups are recommended, so any problems can be identified and treated at an early stage. Serious complications may include:- Scleroderma renal crisis A serious complication with features of accelerated hypertension. Can lead to renal failure if not treated promptly. Occurs in up to 20% of patients with diffuse scleroderma, usually in the first four years of the disease. Occurs in about 5% of patients with limited scleroderma. Presentation: Usually presents as a sudden accelerated hypertension with no urine being passed, Headache, Fatigue, Oedemaswelling of lower legs. Rapidly rising serum creatinine levels, proteinuria and microscopic haematuria (blood in the urine). 10% of scleroderma renal crisis occur with apparently normal blood pressure, but the blood pressure is higher than baseline values - hence the importance of regular blood pressure monitoring. Patients with previous Scleroderma Renal Crisis will have access to the Rheumatology Direct Access Policy - speak to your Rheumatology Clinical Nurse Specialist Comments Contact your Rheumatology Department if any of these symptoms occur Scleroderma Individual Personalised Care Plan 18

19 Other Problems Associated with Scleroderma Gastrointestinal problems People with Scleroderma may develop abnormalities of the digestive system and gastrointestinal tract. Such as Oesophageal dysfunction, Bowel involvement including diarrhoea. Comments See Understanding and Managing Scleroderma Booklet Discuss any new symptoms with the Rheumatology Team. Oral and Dental Problems/Facial Changes The general tightening of skin over the face makes lip and mouth movements as well as oral hygiene difficult. Mircostomia may make it difficult to open the mouth wide enough for dental procedures therefore good, regular dental care is essential Overlap Syndromes of other Connective Tissue Disease Such as Sjogren s/scleroderma Overlap. The most common feature of Sjogren s syndrome are dryness of the eyes and mouth (sicca symptoms). Comments See Oral problems in Scleroderma Leaflet See exercise section for facial exercises Comments See Understanding and Managing Scleroderma Booklet Discuss any new symptoms with the Rheumatology Team. 19 Scleroderma Individual Personalised Care Plan

20 Other Problems Associated with Scleroderma Can help reduce joint swelling and stiffness. NSAID s should be used with caution. Especially if you have problems with your blood pressure, kidneys or heart. One complication of NSAID s is bleeding/ulceration in the stomach and upper intestine. Signs of bleeding/ulceration include stomach pain, blood in stool or dark stools and coffee coloured vomit. Discuss any possible symptoms with your healthcare professional. Scleroderma Individual Personalised Care Plan 20

21 Self Management Advice - Skin Involvement Tight Skin around the fingers, face and other areas of the body causing contractures In addition to drug treatments which you may be receiving physiotherapy and exercise are important to maintain skin movements around joints. Dryness and Irritation of the Skin Regular daily use of moisturisers can help solve this. Some moisturisers have specific ingredients in to combat the itch. Telangiectasia These are burst blood vessels visible as red spots normally on the face and hands. Some treatments are available and may require special funding. Cosmetic camouflage is an effective alternative to cover telangiectasia Contact Changing Faces for general enquires on or Camouflage Comments See The Skin in Systematic Sclerosis leaflet Comments See The Skin in Systematic Sclerosis leaflet. Discuss with your GP or Rheumatology Team for further advice. Comments See The Skin in Systematic Sclerosis leaflet Discuss with your Specialist Nurse how to access this service. 21 Scleroderma Individual Personalised Care Plan

22 Self Management Advice - Skin Involvement Calcinosis Characterized by deposits of calcium in the skin, which may be painful. The calcium deposits may occur just below the skin surface in the form of hard lump or nodules. They break through the skin, becoming visible as chalky white material and may become infected. Comments See advice from the Rheumatology Department Scleroderma Individual Personalised Care Plan 22

23 Living Well with Scleroderma Cardiovascular risk Research has determined that inflammation associated with Scleroderma increases the risk of Cardiovascular Disease and other cardiovascular events. It is therefore recommended that all patients look to lower Cardiovascular risk by treating inflammation and by paying attention to risk factors linked to heart disease:- Smoking Healthy Eating (Cholesterol) Blood Pressure Weight Exercise Smoking Cigarette smoking may flare your Raynaud s symptoms. There is also some evidence that cigarette smoking increases the likelihood of complications. Comments Further advice from GP practices Comments Further advice available from GP practices regarding stopping smoking 23 Scleroderma Individual Personalised Care Plan

24 Self Management Advice - Skin Involvement Healthy Eating It is well-recognised that a healthy diet is important for everyone. Current research supports healthy eating. Maintaining your body weight is important. Scleroderma patients are more likely to lose weight more rapidly and will have difficulty in putting the weight back on and maintaining their weight. Bone Health: Osteoporosis risk Comments See Nutritional tips for Scleroderma patients leaflet Comments Some treatments such as steroid s which can be used to help treat Scleroderma can lower bone mineral density leading to fragile bones. This lower bone mineral density can develop into Osteoporosis meaning you are more susceptible to breaking a bone particularly of the spine, wrist and hip. Eat a healthy diet including foods high in calcium Reduce your alcohol intake Stop Smoking Ensure you remain active and include low impact weight bearing exercises in your weekly regime. Scleroderma Individual Personalised Care Plan 24

25 Personalised Care Plan Department of Rheumatology Problem Symptom Action Comment/review Date Signature Joint and muscle pain Pain and tenderness in hands and feet but can affect multiple joints and muscles. Joint pains can quickly move from one joint to another. Inability to complete activities of daily living due to pain and weakness 25 Scleroderma Individual Personalised Care Plan

26 Activity/Exercise and Scleroderma Why do I need to be active and exercise? To keep muscles strong To keep maximum bone strength To maintain good balance and reduce falls To keep independent with normal activities of life i.e. getting dressed, getting in and out of a chair To reduce risk of conditions such as diabetes, increased cholesterol, To aid sleep and reduce fatigue To maintain a healthy weight To improve general well being and mood To keep joints moving To help ease pain How often should I exercise? Range-of-motion/flexibility exercises can be done daily and should be done at least every other day Strengthening exercises should be performed every other day unless you have painful or swollen joints Cardiovascular exercise should be performed for a total of 150 minutes a week, most people doing 30 minutes 5 times a week. The exercise can be broken down into 10 minute bouts if you find it easier Scleroderma Individual Personalised Care Plan 26

27 Exercise and Scleroderma Hand exercises Facial exercises Cardiovascular & general fitness Stretching and keeping the skin of your hands mobile is essential to help you maintain range of movement of the joints and functional use of the hands If you have been diagnosed with Scleroderma in the past 12 months do not over stretch or be too vigorous with your stretches Keep skin moisturised Use circular massage motions on the skin of the hands to help keep skin supple Try to complete the exercises 3 times a day Try to do your facial exercises on a daily basis Massage your face with gentle circular motions prior to doing your exercises Do a few repetitions of each exercise fast as a warm up Repeat each exercise holding it for a few seconds to stretch a bit longer Do exercises in front of a mirror It is important for all individuals to maintain a healthy cardiovascular system (i.e.: healthy heart and lungs) For those with scleroderma the need for considering your diagnosis and the combination of medications that you may be on is even greater to ensure that you minimise the risk of cardiovascular disease such as heart attacks and strokes Remember that your normal activities during the day are considered as healthy activity, so make sure you try and do some of the following: 27 Scleroderma Individual Personalised Care Plan

28 Exercise and Scleroderma Hand exercises Facial exercises Cardiovascular & general fitness Try to do exercises 10 times each Consider use of wax baths prior to your exercise to help make skin more malleable (NB: seek medical advice if you have a diagnosis of Raynaud s Open your mouth as wide as possible with teeth showing Open your mouth as wide as possible with your lips covering your teeth Wide smile with your teeth showing Take the stairs rather than the lift Park further from the shop door to make you walk further Do some cooking to make you move around Wide smile with your lips closed Push your lower jaw forward to create an under bite Raise your eye brows high Frown Scleroderma Individual Personalised Care Plan 28

29 Exercise and Scleroderma Hand exercises Facial exercises Cardiovascular & general fitness Bend your wrists forward Close your eyes tight Walking Bend your wrist backwards Make a tight fist then spread your fingers straight and wide Make a high fist (bend your finger tips only to touch the top of your palm) Place palms of hands together and using the knuckle joints try to make a diamond shape (keep finger tips and wrists together) Resting your hand on your lap turn your palm facing up and then down Wrinkle to bridge of your nose Wink each eye Puff your cheeks out Flare your nostrils Swimming Cycling Chair based exercise Nordic walking Pilates Yoga There are many more forms of exercise that may be suitable for you take the opportunity to discuss these with your physiotherapist 29 Scleroderma Individual Personalised Care Plan

30 Exercise and Scleroderma Hand exercises Facial exercises Cardiovascular & general fitness Tap the tip of each finger with your thumb Tap the base of your little finger with your thumb Scleroderma Individual Personalised Care Plan 30

31 Exercise and Pulmonary Hypertension Exercise and pulmonary hypertension Having Pulmonary hypertension can make it hard for some to exercise to a degree that will work their cardiovascular system vigorously. For those with shortness of breath on mild or moderate exertion it is recommended that you work with your physiotherapist or nursing team to ensure suitable activities / exercises are being undertaken. For those who are short of breath at rest or on mild exertion, exercise should only be undertaken with supervision. If you feel any symptoms of dizziness, increased levels of shortness of breath above what is normal for you, or any other symptoms of concern, stop your exercise and seek medical advice Remember, your tolerance to exercise and the suitability of different activities and exercise may vary according to your condition. Please ensure you seek regular review with your health care team to ensure your level of activity /exercise is still right for you. 31 Scleroderma Individual Personalised Care Plan

32 Managing Pain Not all people present with the same location, frequency, intensity or duration of pain. Some have mild ongoing pain, some have gradually increasing pain, others will have episodes of intense pain and then be relatively pain free for a period of time everybody is different. It is not possible to predict who will experience what pain levels. Self management actions to reduce or control your pain levels include: Taking your medication as prescribed (if applicable) Keeping a good posture Exercising regularly Pacing your activities Minimising stress levels Have a dedicated time to practice relaxation techniques each day. Cool and Heat packs can prove effective. Caution when using cool and heat packs if experiencing Raynaud s symptoms avoiding rapid temperature changes. It is essential to remember that not all pain is harmful. A level of discomfort as you exercise is expected but this will not be causing any physical harm if you are performing the right exercise in the right way and at the correct level. Scleroderma Individual Personalised Care Plan 32

33 Personalised Care Plan Department of Rheumatology Problem Symptom Action Comment/review Fatigue Tiredness unrelieved by Date Signature rest Lack of energy or motivation Poor concentration or memory Apathy or not caring what happens All other causes of fatigue excluded 33 Scleroderma Individual Personalised Care Plan

34 Personalised Care Plan Department of Rheumatology Problem Symptom Action Comment/review Raynaud Affects blood vessels Date Signature in the fingers, toes, nose or ears A change in temperature causes skin to go, blue, white then red avoid rapid temperature changes, warm up slowly. Causes pain, tingling and numbness of affected areas Can reduce hand function and can cause finger ulcers Scleroderma Individual Personalised Care Plan 34

35 Personalised Care Plan Department of Rheumatology Problem Symptom Action Comment/review Raynaud See your podiatrist for Date Signature insoles that help keep the warmth in your shoes when out and about in cold weather Some creams are available which can help manage pre-ulcerative sites discuss with the Rheumatology Team 35 Scleroderma Individual Personalised Care Plan

36 Personalised Care Plan Department of Rheumatology Problem Self management advice Anxiety, low mood or depression Many factors can contribute to the symptoms of anxiety and depression including: Having a diagnosis of a long term condition Pain levels Fatigue levels / reduced sleep Loss of functional independence Reduced ability to work /remain productive at work Action Comment/review Consider counselling to help you to come to terms with your diagnosis / current state. Contact your GP for advise on effective medications Exercise regularly this can help the body produce its own painkilling chemicals and give you a sense of well being Talk to family and friends let them know how you are feeling and that it can be part of your condition Use support groups Date Signature Scleroderma Individual Personalised Care Plan 36

37 Personalised Care Plan Department of Rheumatology Problem Self management advice Action Evaluation Date Signature Medication Steroids for some patients Steroids are the first line of medication. Steroids should be taken on a regular basis at no point must steroids be stopped without prior discussion with the Consultant Rheumatologist. IV or IM steroids may be needed. AR UK leaflets- Steroids Methotrexate Mycophenolate Cyclophosphamide Azathioprine Hydroxychloroquine Monitoring Disease Modifying Anti Rheumatoid Drugs (DMARDS) are the other medications important in managing Scleroderma The Department of Rheumatology holds all of the AR UK Leaflets or visit www. arthritisresearch.uk.org 37 Scleroderma Individual Personalised Care Plan

38 Medication People with Scleroderma are likely to take several prescriptions and over the counter medications, and the more drugs you take for the conditions you develop, the greater the chance that you ll experience side effects, medications interacting or the potential you mistakenly take the wrong drug or dose. You can help avoid these problems by getting organised and making sure your medical team and pharmacist know about all of the prescription drugs you re taking. Top Tips Make a list. Keep an updated list of all your over-thecounter and prescription medications with you at all times so you can share it with each member of your health care team when you go to doctor visits and get prescriptions filled. Include the name of each medication you are taking, along with the dosage information and the reason you are taking it. Give a copy of your medication to your next of kin Look to see if the Message in a bottle scheme can help you. Maintain a prescription medication file. After you read the written material that accompanies your prescription medication, file it in a place where you can find it easily should you ever have questions about dosage or side effects. Use one pharmacy. If possible, have all of your medications filled at the same pharmacy, so that your pharmacist can track them all and alert you to possible drug interactions. Medication Review. Ask your Pharmacy for a yearly medication review. Do not over stock- only order repeat prescription. Message in a bottle: Available from Lions Clubs Headquarters on or by mdhq@lions.org.uk Scleroderma Individual Personalised Care Plan 38

39 Managing my Scleroderma symptoms Symptoms Self-Management Plan Comment/review 39 Scleroderma Individual Personalised Care Plan

40 My Personal Goals Date Goal I would like to achieve What actions am I going to take to achieve it By when Date achieved Scleroderma Individual Personalised Care Plan 40

41 Patient Support Groups When beginning to live with a disease such as Scleroderma you and your family will have many questions. Some of which will be very specific to the disease itself whilst others will be related to just getting on with living with Scleroderma. You will find a wealth of information from Scleroderma and Raynaud s charities, who also can direct you to the best possible answers to your questions about your health, future, happiness, independence and relationships. Also, be sure to ask other Scleroderma patients for their solutions to some of the problems you are beginning to face, both practical and emotional. Supporting and participating in local support groups, and their online chat forums, offers no better place to gain understanding about living with Scleroderma than from a group of people who live with the condition. The interaction with a larger group offers you a broader scope of understanding, especially since not all people with Scleroderma have identical symptoms, undergo the same treatments, or cope the same way. We can learn from each other and from shared experiences. Both Charities also produce a wealth of information booklets, information sheets and resources. 41 Scleroderma Individual Personalised Care Plan

42 Patient Support Groups The Scleroderma Society Bride House Bride Street London EC4Y 8EE Phone: co.uk Webpage: co.uk Raynaud s and Scleroderma Association 112 Crewe Road, Alsager Cheshire ST7 2JA Phone: or info@raynauds.org.uk Webpage: Produced by: Rheumatology Department Date: June 2015 Review: June 2017 Ref: P W Medical Illustration ref: 15/1152 Portsmouth Hospitals NHS Trust 2015 Scleroderma Individual Personalised Care Plan 42

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