Nursing Reviews

With COVID-19 public lockdown and advice for those with comorbidities to socially isolate is the responsibility of the surgery to make sure these patients continue to have good quality chronic disease reviews in a way that does not in turn put them at increased risk. 

We know that a GP surgery is a likely mixing pot of infection transmission so managing these health reviews by phone, video consult (products similar to Skype) or email is of clear benefit to the patient and other patients who use the surgery. The first question to ask is if the patient definately requires a review or can this be safely postponed to a safer period? If the patient definately requires a review then the question should be: Can this be done via phone or video consultation?

Below is not meant as a fixed idea on how these things are done. It is just some suggestions on how the reviews may be adapted in this difficult time. I am aware that no all surgeries will be as comfortable with their nursing colleagues doing as below and some surgeries will have additional services, which need to be adapted. Everything needs to be adapted to local practice protocols that the whole team are happy with. I hope at the very least it is a helpful way of thinking about a different approach

Patients concerend about specifics to do with COVID-19, or related to their health conditoins and COVID-19 can be directed to an updated practice website with accurate web resources.

Read our Blog on Patient Information

Asthma Reviews

Review compliance of prescribed medication

Review control with 3RCP Questions:

1.       In the last month have you had difficulty sleeping because of your asthma symptoms (including cough)?
2.       In the last month have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?
3.       In the last month has your asthma interfered with you usual activities (for example, housework, work/school, etc)?

If patient has Peak flow meter ask patient to check and give best of 3 readings.

If patient does not have peak flow get prescription done for this and ask patient to re-contact surgery with readings when taken.

If on video consultation check inhaler technique using camera.

If over phone ask patient to describe inhaler technique and text through following advice page to confirm understanding: https://www.asthma.org.uk/advice/inhaler-videos/

Adjust or renew medication in line with practice policy and review period as appropriate for experience of nurse doing review

Create 'asthma management plan' – these can be downloaded and sent to patient via email at  https://www.asthma.org.uk/advice/manage-your-asthma/action-plan/

If patient reports concerns re: COVID-19 text them a link to: https://www.asthma.org.uk/advice/triggers/coronavirus-covid-19/

If acutely very breathless with cough or fever discuss with GP or advise visit 111 for Public Health advice:  https://111.nhs.uk/covid-19

COPD Reviews

Smoking status and smoking cessation advice/support.

Check compliance, side effects and symptom control: breathlessness, exercise tolerance, estimated exacerbation frequency.

Check inhaler technique if possible as above.

Record MRC Dyspnoea Score.

Patient checks weight – calculate BMI offer weight management advice if appropriate.

Check vaccination status – consider pneumococcal and influenza vaccinations if safe and appropriate for patient to attend.

Co-develop a personalised self-management plan including exacerbation plan: Consider rescue pack.

If concerns regarding COVID-19 direct to https://www.blf.org.uk/support-for-you/coronavirus/people-living-with-lung-condition

If patient monitors own O2 Saturation record levels.

If symptoms stable, consider reschedule for F2F at future date when current situation has settled for Spirometry review.

Diabetes Reviews

If no recent changes to Diabetic management and for period of COVID-19 switch from 6monthly reviews to annual reviews.

If required (is > 12 months since last) bloods via Phlebotomy (try to limit use of DN teams and if really needed consider delay of review by 4 months.)

Via telephone or video consultation ask patient to weigh themselves.

If Home blood pressure measurement available check BP also.

Discuss exercise, smoking and diet as normal. Review bloods as normal.

Reinforce advice through advice via text such as Pocket medic:

If patient under podiatry – document.

If not discuss diabetic foot care and share website: https://www.diabetes.co.uk/diabetes-footcare.html

If high risk – ie previous neuropathy or ulcers consider F2F review but discuss pros and cons with patient. Consider walk in podiatry service if patient well and service still running.

If required make medication changes. Consider pros and cons of changes above lifestyle measures in view of situation with access and demand at time of review.

For patients undertaking glucose monitoring review plan for high and low sugars and sick day rules.

Type 1 patients: https://trend-uk.org/wp-content/uploads/2019/01/A5_T1Illness_TREND_FINAL.pdf

Type 2 patients:  https://trend-uk.org/wp-content/uploads/2018/12/A5_T2Illness_TREND.pdf

Adjust or renew medication in line with practice policy and review period as appropriate for experience of nurse doing review

Hypertension Reviews

Via phone or video consult. Discuss compliance and possible side effects.

Lifestyle advice:

• Reduce the amount of salt you eat and have a generally healthy diet
• Cut back on alcohol 
• Lose weight if you're overweight
• Exercise regularly
• Cut down on caffeine
• Stop smoking

Consider directing or texting link to https://www.nhs.uk/conditions/high-blood-pressure-hypertension/

If patient has home BP machine, ask them to check and give you readings – consider average reading of 3.

If patient on ACE or ARB do they have up to date U&E bloods. If not discuss pros and cons of coming to surgery for blood tests.

Reinforce advice not to attend if suffering from COVID type symptoms.

If patient does not have home device- discuss pros and cons of coming to surgery for monitoring.

IF patient on ACE or ARB do they have up to date U&E bloods.

OPTIONS:

1.        Patient would prefer to purchase device check home readings themselves and rebook
2.        Patient needs blood tests as above then rebooks for phone or face to face BP check
3.        Last check within last 9 months agree to leave for 6 months and review situation

Reinforce advice not to attend surgery if suffering from COVID type symptoms.

If BP in range complete review.

If not consider lifestyle adjustments or changes to medication which do not require blood test monitoring. Adjust or renew medication in line with practice policy and review period as appropriate for experience of nurse doing review.

CKD Reviews

BP review as above with U&E and Urine Alb/creatinine ratio if not in last 9 months to discuss pros and cons of attending surgery for test.

Reinforce advice not to attend if suffering from COVID type symptoms.

AF Reviews

Instruct patient how to check their radial pulse. If struggling video instruction can be sent via text: https://www.youtube.com/watch?v=qaZrzoH8Jvk&feature=youtu.be

Ask patient to yes each time they feel their pulse for you to count rate and check rhythm.

BP check as above is possible.

HASBLED and CHADVASC from information available.

NOAC Patients:

If up to date bloods calculate Cockroft and Gault.

If no bloods in last 6months discuss pros and cons of attending surgery for bloods.

Warfarin Patients:

Consider switch to NOAC – discuss pros and cons of this consider review with GP at INR appointment to discuss and potential switch.

Reinforce advice not to attend if suffering from COVID type symptoms.

Heart Failure Reviews

Check medication compliance, potential side effects and symptom control.

BP pulse review as above.

U&E bloods if not in last 9 months to discuss pros and cons of attending surgery for test.

Reinforce advice not to attend if suffering from COVID type symptoms.

If poor or worsening control telephone f/u with GP.

Epilepsy Review

• Telephone review of compliance with medication and potential side effects.
  • Last seizure date and fit frequency.
• If poor or worsening control telephone f/u with GP.

Wound Care

Obviously wound care requires F2F review but if the patient begins to develop COVID symptoms this may become very difficult. If ongoing wound care and dressings, consider encouraging patient to use video consultation programs when available for ongoing monitoring:

Could the patient or a relative/carer apply their own dressings with video updates on progress? (amount of dressings supplied would need to be considered).

Reinforce advice not to attend if suffering from COVID type symptoms.

Contraception and HRT

Oral contraception:

• Most checks can be done over phone.
• Check compliance and side effects over phone.
• PT can weight themselves and check home BP if available.
• If not available discuss pros and cons of coming to surgery to get checked. IF BP on record in last 12 months in safe range consider repeat script till safer time to recheck.
• UKMEC score questions as normal via phone
• Consider 6-12 month supplies where possible

If Depot contraception or high risk to continue script for F2F but - Reinforce advice not to attend if suffering from COVID type symptoms

Read our Cardiff & Vale Sexual Health Clinic Advice Blog

INR Monitoring (non AF)

Obviously a lot of these patient will still need to be seen but Consider the following

1. Can patient safely be moved to a NOAC?
   • If so arrange bloods and counselling with clinician to convert
2. Not suitable for most patients but is home monitoring an option? Pts need to be well trained and motivated. Not appropriate for every patient due to high risk if not performed correctly. Is patient willing to purchase home monitoring kit and email results to surgery for dosing? (protocol in place at North Cardiff Medical Centre)