Management of long term conditions
Management of long term conditions This assignment will reflect on an aspect of care in the management of asthma as a long term condition in the primary care setting. It will specifically focus on patient compliance and how it affects good asthma control. A case study of a 22 year old female patient who suffers from asthma will be used to explore the significance of compliance In the management of asthma and the benefits it can have to patient outcomes. The discussion will Include areas relating to patient education, medication management and National Health Service strategies In asthma management.
Also the role of the general practice nurse will be analyses in determining care delivery through assessment, planning and evaluation of patient outcomes. To help in the reflection process Gibbs reflective cycle (Gibbs 1988) will be used. To respect confidentiality In accordance with the Nursing and Midwifery council (2004) the patient’s name has been changed and will be referred to as All. Asthma is part of a group of conditions which include, but is not limited to, COOP, depression, diabetes and cardiac vascular disease, all of which are referred to as long term conditions.
A long term condition (LET) can be defined as
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Carrier (2009) states that with acute disease the aim of the treatment is to return the person to a normal healthy state but with a chronic Eng term condition the patient’s life is irreversibly changed, and possibly that of their families too. This can cause additional problems such as Isolation, financial loss, low self esteem and depression. Therefore by attempting to optimism the physical health of people living with a long term conditions It may be possible to improve the negative impact on other areas of their life.
This not only has a positive effect for the patient but also has a positive effect on cost implications to the National Health Service (NASH) as a whole. According to the British Thoracic Society (asthmatic Is a common condition which s estimated to affect 300 million people worldwide and more than 5 million people in the United Kingdom Evans & Tiepins (2007) define asthma as a common long term condition of the upper respiratory tract which is prone to acute exacerbations in response to hypersensitivity reactions triggered by a stimulus. The reaction to stimulus, or antigens, causes the airways to become inflamed which leads to constriction.
The triggers for an exacerbation of asthma can Include animal, mites, include wheezing on inspiration, shortness of breath, a tight chest and a cough. It is molly treated with prognosticators and anti-inflammatory drugs which can have a positive outcome if managed appropriately. The Royal College of Physicians (RCA 2003)have stated that the management of asthma can be effectively undertaken in the primary care setting. However, the care needs to be delivered in a structured proactive way to achieve the best results, and if done correctly, can significantly reduce exacerbation rates and days lost from normal activity.
In the general practice setting this role has increasingly been undertaken by the general practice nurse (GAP) by way of an annual asthma review. The GAP is in n ideal position to plan, implement and monitor care of the asthma patient, however, it needs to be recognized that the best laid plans will fail if there is little co- operation from the patient who will need to be responsible for managing their condition on a day-to-day basis (Boston-Cox 2013). Patient co-operation in managing a long term condition can be referred to as patient compliance.
Compliance is defined as being obedient and passive, for example, if the GAP says the patient needs to take his medication then he should take it. However, McKinney (2013) states that concordance is more desirable and defines it as being a readership of equals between patients and practitioners, where patients are recognized as experts in their own life. This partnership allows for an informed and shared decision making about the patient’s care planning. For the purposes of this assignment the term compliance will be used but the intention is that the terms, compliance/concordance, are interchangeable.
Snowmen et al (2013) argue that while it is relatively easy to identify people that are not compliant it is more difficult to identify why they are not compliant. However, Lindsay and Haney (2013) dispute this and state that it is not so easy to identify these patients. They argue that there is no consistent link between socioeconomic status and non-compliance and that there is a perception that the “typical” non-compliant patient would be one who smokes, has a chaotic lifestyle or has other high risk factors.
Therefore this highlights the importance of using a systematic approach to patient assessment by the GAP during the asthma consultation so that the assessment can be objective and accurate and that no assumptions are made. The case study that will be analyses for the purpose of this assignment is that of a 22 year old woman called All, a business graduate. All was diagnosed with asthma at the age of 9 years old and had generally managed her asthma well with regular attendance to her annual asthma reviews.
Since starting university though she had not bothered to go for annual reviews and often delayed renewing her inhalers when they ran out. She thought that she had probably ‘grown out’ of her asthma as it was years since she had really been bothered by any serious symptoms. However, her symptoms had started to become a problem particularly in the winter months in the cold damp weather. She also noticed more symptoms when she exercised. She mound this frustrating as she had started rowing at university and now working would coughing and wheezing.
According to the British Thoracic Society (2007) well controlled asthma is defined as having no symptoms during the day or that wake the person up at night, no need for rescue medication, no exacerbations, and there should be no limitations on activity including exercise. During the consultation the GAP used an open and friendly approach to explore Alias understanding about her condition and to gauge how much knowledge she had about her asthma. Boston-Cox (2013) explains that to understand the patient’s respective of their condition is the first step in a consultation and is often overlooked.
The asthma review consultation allows the GAP the opportunity to explore the patient’s own relationship with their condition and how it may impact their current and future compliance. Small et al (2011) highlight some of the common reasons that people do not take their medication: they are in denial that they have a problem, they do not understand how the medication works and feel it’s a waste of money, they feel embarrassed that they need to use their inhaler while in public or with friends, that they are not happy with the inhaler they using.
Without addressing these issues around compliance it is unlikely that the patient will achieve good control of their asthma. All admitted that she did not take her inhaled corticosteroid anymore saying she could not see the benefit of it. She preferred to rely on her Salomon inhaler as she could see the immediate effect and felt reassured, she estimated that she used it up to 10 times per week. However, during a particularly bad exacerbation of her asthma she had taken herself to the accident and emergency department as she had did not have a Salomon inhaler and become frightened.
This episode had romped her to realize that she needed to seek help in an attempt to get her asthma back under control. Every day more than two hundred people are admitted to hospital in the I-J due to their asthma and it is estimated that up to seventy-five percent of these people could have avoided hospital admission if their asthma had been properly managed Cones 2013). The GAP could clearly see that All did not have a good understanding of her asthma or her medication and this was a possible reason for her non-compliance.
Although asthma is an incurable disease Asthma I-J states that if a patient takes the right dedication properly they should rarely have asthma symptoms and the condition can be well controlled. In the long Journey facing practitioners and patients in the management of a long term condition this is a process worth investing time in to optimism good outcomes Jones et al (2001). It is thought that the nurse-patient relationship is unique and can be central to optimizing the management of long term conditions such as asthma.
During the assessment process the GAP needs to ensure that the patient has every opportunity to discuss their concerns about their asthma symptoms and a potential hospital admission. The role of the practice nurse has an ever increasing range of duties; conducting asthma monitoring assessments is an example of one additional. The GAP has a responsibility to ensure that she is fit for the role and needs to give serious consideration to her training needs.
The role of the GAP needs to be clearly defined by the practice and there should be a clear understanding how the GAP should undertake the asthma assessment. Robinson (2009) argues that some Gaps are resistant to handing over the responsibility to nurses to monitor the patient’s and becomes a barrier to optimizing patient self care. As an integral part of the team in a general practice the practice nurse (GAP) plays a key role in the delivery of better care.
Boston-Cox & Dews (2012) state that Span’s are experienced clinicians capable of critical thinking and innovation who strive to deliver good quality, evidence based and cost effective care. However, they argue that this fact is sometimes overlooked during management decisions, this then becomes a challenge for Gaps to be recognized as having an important contribution to make in determining patient care. There is the danger that the assessment Just becomes a box-ticking exercise to attics the Quality and Outcomes Framework criteria at the expense of the patient’s health.
This then furthermore highlights the importance of the GAP having a comprehensive understanding of the condition so that can conduct a thorough and proper patient assessment. The GAP reflected on the way she had conducted her asthma clinic consultations with other patients and decided that she should reconsider her approach to the assessment process. By using Gibbs reflective cycle she was able to reflect constructively on the problem and to think about how she could improve the quality of her assessment in the future.
She felt that maybe she had been at fault in assuming that her patients understood their condition better than they did. According to the British guidelines on the management of asthma (SIGN 2013) for education in self-management of the condition requires a gradual transition of care so that the person can independently manage their asthma. The self-management skills could not be learnt in one sitting and would require effort from both herself and her patients as part of an ongoing relationship.
The nurse needs to use her skills during the consultation to develop a patient- focused rapport which addresses the individual needs of the patient. A consideration of the different age groups that she may encounter during a consultation will mean that she will have to adapt her technique when trying to technology or app to monitor their asthma whereas an older person may prefer to just have a written action plan which can help to measure and monitor outcomes.
There are many resources available to healthcare professionals and patients which can easily be accessed. For example, using the computer to view animated demonstrations to show the physiological changes in asthma, printing off action plans and personalizing them, recommending mobile phone APS which would be lawful in monitoring asthma such as My Asthma app (mastery. Com 2013). Telephone consultations are also an additional way to monitor patients who might not be difficult to get into an appointment.
In an attempt to make the consultation more patient-focused the GAP she asked All what she would like to achieve from the consultation today. Having admitted that she felt quite ignorant about her condition she said she would like some help in understanding what asthma is and how the medication helps. The GAP explained to All the rationale for asthma monitoring and the strategies put in lace by the overspent to help the process. For example, the National Institute of Health and Care Excellence (2008) given clear guidelines in how this should be conducted.
For example, regular asthma reviews at least yearly, peak expiratory flow measurements to determine what is occurring in the airways, prescribing the correct medication and good medication compliance to prevent exacerbation and hospital admissions. The GAP and All agreed that a personalized action plan would be useful to underline the key components of good asthma control and facilitate effective self-management (Boston-Cox 2013). The GAP asked All to perform a peak expiratory flow meter (PEP) which measures the fastest rate of air you can blow out of the lungs.
It is measured in litter per minute and All recorded 370/1 which was the best of three attempts. This was lower than her predicted rate of 450/1 which is calculated using her height and her age, she was unsure of her best previously recorded score. During the consultation All had already stated that she was experiencing symptoms during her sleep, the day and also interfered with her daily activities which indicated that her asthma was not well controlled. This information is important as it gives a real sense of how the patient is able to cope with their symptoms and ultimately how much control they have over their asthma.
The BETS SIGN guidelines state that asthma monitoring should consist of three questions as follows: In the past week/month…… 1. Have you had any difficulty sleeping due to your asthma symptoms? 2. Have you had your usual asthma symptoms during the day (cough, wheeze, tight chest and shortness of breath)? 3. Has your asthma interfered with your usual activities (housework, work, school)? Studies have been shown to suggest that the three RCA questions, along with PEP and ornithological usage, are the most beneficial audit tool in determining asthma control.
Other methods of monitoring asthma, for example, lung function testing, were not as effective by comparison when determining treatment outcomes (Thomas following in addition to the previously mentioned assessments: Check inhaler technique Check smoking status Discuss influenza vaccination Assess trigger factors Adjust therapy, step up or down (if qualified to do so or refer to GAP) The use of drugs in chronic asthma can be approached in stages determined by factors such as age, severity and pattern of attacks (BETS).
If the treatment is not sufficient in controlling the asthma then the practitioner can step up to the next level which adds another form of medication to the regime. In total there are five steps as shown in appendix one. All has been on step two for her asthma which consists off metered dose inhaler of Salomon to use as a rescue medication when required and also a corticosteroid inhaler of baccalaureates MGM, to be taken twice in the morning and twice in the evening.
Salomon is a powerful bronchiolar (82 agonies) that works quickly and lasts up to four hours. Corticosteroids reduced the inflammatory and allergic aspects of asthma and decrease the brontosaurs in persistent and severe asthma. It is widely acknowledge that asthma is best controlled through the use of corticosteroids but the outcomes will always be determined by patient compliance.
It was agreed between the GAP and All that she was probably on the right step of the treatment plan but as she had not adhered to the regime it had had a detrimental effect on the management of her asthma. Adherence is often considered poor in adolescence, therefore as a person matures and has a better understanding of why hey should comply with the prescribed regime better outcomes should be seen.