Carer Diary

CARiAD Carer Diary v1 Mar 2020

Patient's name

DOB

NHS number

Address

CARiAD Carer Diary v1 Mar 2020

To assist you in your caring role, this diary has been developed specifically to assist you with recording the as-needed subcutaneous medications that are given to the person you are caring for each day. You should complete a page in this diary each time the person you are caring for experiences a breakthrough symptom that requires as-needed subcutaneous medication, even if you do not administer the medication yourself.

This diary is one part of the CARiAD package for carers. The diary is based on the study materials of a Bangor University research study, which was adapted from the Brisbane South Palliative Care Collaborative Caring Safely at Home booklet entitled ‘Caregiver Daily Medication Diary’. It is only to be used in conjunction with thorough training from local healthcare teams.

There are instructions on how to use the diary on the following pages and your healthcare team will go through these with you. If you have any further questions please speak to your healthcare team.

Page: 2

CARiAD Carer Diary v1 Mar 2020

Contact Details

District Nurse Service

Team

Named DN (if applicable)

Contact details

Working hours

In hours GP service

GP Surgery

Usual GP (if applicable)

Contact details

Working hours

Out of Hours GP Service

Contact details

Working hours

Local Pharmacy

Name

Telephone

Fax/Email

Page: 3

Specialist Palliative Care Service

Team

Named DN (if applicable)

Contact details

Working hours

Other important contacts

Person or service

Named Contact (if applicable)

Contact details

Working hours

CARiAD Carer Diary v1 Mar 2020

Person or service

Contact details

Working hours

Page: 4

Carer diary instructions

For each medication you give, please complete the following:

Date and time that symptom developed

(30/11/16)8.35 pm

Noted by:Patient

Carer4

4

Breakthrough symptom

PainNausea/vomiting Anxiety orAgitation/restlessnessNoisy 'rattly' breathingBreathlessness

Write the date (day/month/year) and time that you or the person you are caring for feels that a symptom is developing that is not being controlled by any regular medication or previous doses of as-needed medication.

Tick the box to indicate who noted the symptom developing.

Tick the box which best explains the reason you are giving the medication. Sometimes you may need to give different medications, for example one for pain and one for nausea. If so, record each on a separate page.

If possible, ask the person how they would rate their symptom on a scale of 0-10, where 0 is no symptom and 10 indicates the worst that symptom can possibly be. If the person is not able to tell you, you can record how bad you think the symptom is in your experience of caring for the person. Record the number for the symptom. This will help you to see later on if the symptom has improved.

Tick the box to show who rated how bad the symptom was, you or the patient.

4

Symptom score before(0-10)

7

Assessed by:Patient

Carer

CARiAD Carer Diary v1 Mar 2020 Page: 5

/10

HCP

Dose

50 mg

Write the name of the medication each time you give it.

Tick the box to show if you gave the medication or if a healthcare professional (HCP) was called and gave it.

Write the dose of the medication each time you give it. Remember to put the number and the units (the letters after the number). You should check this is correct using the chart at the front of your diary before giving the medication.

Write the time that the as-needed medication was given.

After 30 minutes have passed since the medication was given, check to see if the symptom has improved. Again, if possible, ask the person how they would rate their symptom on a scale of 0-10, where 0 is no symptom and 10 indicates the worst that symptom can possibly be. If the person is not able to tell you, you can record how severe you think the symptom is in your experience of caring for the person. Record the number for the symptom.

Tick the box to show who rated how severe the symptom was. This may be you, the patient or a healthcare professional if one was called.

Remember: Everyone is different and for some people, the as-needed medications can take between 15-30 minutes to work. Allow this time for the medication to work before checking and recording the symptom score for this section of the diary. If you are concerned you can contact your doctor or nurse for further advice.

Time medication was given at

8.55 pm

CARiAD Carer Diary v1 Mar 2020

Medication given

Name:Cyclizine

Given by:CarerHCP

4

4

Symptom score 30 minutes after medication (0-10)

3 /10

Assessed by:Patient

CarerHCP

Page: 6

4

4

When were symptoms resolved to an acceptable level?

Within 30 minsof medicationIf longer please specify time:

Assessed by:Patient

CarerHCP

CARiAD Carer Diary v1 Mar 2020

How confident were you in giving the injection

When the patient’s symptoms have improved to an acceptable level, tick the box to indicate if this happened within 30 minutes of the medication being given, or if it took longer. If it took longer than 30 minutes, write down the time it took for the symptom to improve to an acceptable level.

Tick the box to show who made the assessment of when the symptom was resolved. This may be you, the patient or a healthcare professional if one was called.

If you gave the medication, rate how confident you were in preparing and giving the injection on a scale of 1-10

(1 = not at all confident,10 = extremely confident).

Tick the box to indicate if you called a healthcare professional (such as a nurse or out of hours services) to visit you at home as a result of the breakthrough symptom. If so, there is a section at the bottom of the page they should complete.

4

3 / 10

Was healthcare professional support sought?

Yes No

At the bottom of the table there is a space for you to add any extra comments that might be helpful to you. This can be anything that you might want to remind yourself of later or anything you might want to remember to discuss with the person’s healthcare team.

Please remember to write down your initials in the 'Carer initials' box.

It is important that no pages are removed from your diary. If you make a mistake, cross it out and use a fresh page. If you are running out of space in your diary you should let your healthcare team know.

Page: 7

CARiAD Carer Diary v1 Mar 2020

Brea

kthr

ough

A

s-ne

eded

D

ose

Volu

me

Max

imum

Sp

ecia

l Ins

truc

tion

s sy

mpt

oms

med

icati

on

need

ed fo

r nu

mbe

r of

(e

.g. a

dditi

onal

re

quir

ed

dose

s in

to

p up

dos

es)

dose

24

hrs

(3 o

r few

er)

Reas

ons f

or d

ose

chan

ge (a

lso e

nsur

e do

ses n

o lo

nger

rele

vant

ar

e cr

osse

d ou

t cle

arly

)

Page: 8

Pain

Anxi

ety

orAg

itatio

n/re

stle

ssne

ss

CARiAD Carer Diary v1 Mar 2020

Brea

kthr

ough

A

s-ne

eded

D

ose

Volu

me

Max

imum

Sp

ecia

l Ins

truc

tion

s sy

mpt

oms

med

icati

on

need

ed fo

r nu

mbe

r of

(e

.g. a

dditi

onal

re

quir

ed

dose

s in

to

p up

dos

es)

dose

24

hrs

(3 o

r few

er)

Reas

ons f

or d

ose

chan

ge (a

lso e

nsur

e do

ses n

o lo

nger

rele

vant

ar

e cr

osse

d ou

t cle

arly

)

Nau

sea

orvo

miti

ng

Noi

sy 'r

attly

'br

eath

ing

Page: 9

Brea

thle

ssne

ss

CARiAD Carer Diary v1 Mar 2020

Dat

e an

d ti

me

Brea

kthr

ough

Sy

mpt

om

Med

icati

on

Dos

e Ti

me

Sym

ptom

W

hen

wer

e H

ow

Was

hea

lthca

re p

rofe

ssio

nal

that

sym

ptom

sy

mpt

om

scor

e be

fore

gi

ven

med

icati

on

scor

e 30

sy

mpt

oms

confi

dent

supp

ort s

ough

t?

deve

lope

d (0

-10)

w

as g

iven

m

inut

es a

fter

re

solv

ed to

an

wer

e yo

u in

at

med

icati

on

acce

ptab

le

givi

ng th

e(0

-10)

leve

l?in

jecti

on

__/_

_/__

N

ame:

___:

____

__

__ /

10

W

ithi

n 30

Y

es

am/p

m

m

ins

of

N

o

m

edic

ation

I

f lon

ger

___

:___

_

ple

ase

am/p

m

s

peci

fy ti

me:

Not

ed b

y:

Ass

esse

d by

: G

iven

by:

A

sses

sed

by:

Ass

esse

d by

:

Pati

ent

P

atien

t

Car

er

P

atien

t

Pati

ent

Ca

rer

C

arer

HCP

Car

er

C

arer

H

CP

H

CP

H

CP

Care

r com

men

ts

Sect

ion

to b

e co

mpl

eted

by

HCP

(if a

pplic

able

):

HCP

det

ails

(Nam

e, p

rofe

ssio

nal r

ole,

sign

atur

e)Ti

me

Ass

essm

ent m

ade

Out

com

eatt

ende

d

Page:10Entry: 1

____

/ 1

0

P

ain

Nau

sea/

Anxi

ety

or

N

oisy

'rat

tly'

b

reat

hing

Brea

thle

ss-

ness

Agita

tion/

rest

less

ness

vomiting

Tim

e A

sses

smen

t mad

e:

Out

com

e:att

ende

d

Care

r initia

ls

Care

r initia

ls

and

sign

atur

e

(10

= w

orst

)

(10

= w

orst

) (0

-10)

(10

= most

confiden

t)

H

CP

____

/ 1

0

CARiAD Carer Diary v1 Mar 2020Page: 11

Dat

e an

d ti

me

Brea

kthr

ough

Sy

mpt

om

Med

icati

on

Dos

e Ti

me

Sym

ptom

W

hen

wer

e th

at s

ympt

om

sym

ptom

sc

ore

befo

re

give

n m

edic

ation

sc

ore

30

sym

ptom

s de

velo

ped

(0-1

0)

was

giv

en

min

utes

aft

er

reso

lved

to a

n at

m

edic

ation

ac

cept

able

(0

-10)

leve

l?

__/_

_/__

N

ame:

___:

____

__

__ /

10

W

ithi

n 30

am/p

m

m

ins

of

m

edic

ation

I

f lon

ger

___

:___

_

ple

ase

am/p

m

s

peci

fy ti

me:

Not

ed b

y:

Ass

esse

d by

: G

iven

by:

A

sses

sed

by:

Ass

esse

d by

:

Pati

ent

P

atien

t

Car

er

P

atien

t

Pati

ent

Ca

rer

C

arer

HCP

Car

er

C

arer

H

CP

H

CP

H

CP

Entry: 2

P

ain

Nau

sea/

Anxi

ety

or

N

oisy

'rat

tly'

b

reat

hing

Brea

thle

ss-

ness

Agita

tion/

rest

less

ness

vomiting

____

/ 1

0

Tim

e A

sses

smen

t mad

e O

utco

me

atten

ded

Sect

ion

to b

e co

mpl

eted

by

HCP

(if a

pplic

able

): H

CP d

etai

ls (N

ame,

pro

fess

iona

l rol

e, si

gnat

ure)

Care

r initia

lsan

d si

gnat

ure

How

co

nfide

nt in

givi

ngw

ere

you

the

inje

ction

(0-1

0)(1

0 = most

confiden

t)

____

/ 1

0

(10

= w

orst

)

(10

= w

orst

)

H

CP

Care

r com

men

tsW

as h

ealth

care

pro

fess

iona

l su

ppor

t sou

ght?

Y

es

No

Subcutaneous Medicationsand Palliative Care:

A guide for caregivers

Subcutaneous Medicationsand Palliative Care:

A guide for caregivers