Learning outcome 1
The chronicity of COPD allows for self management by sufferers. (Spencer & Barcomb 2014). The self management goal is reduced hospital admissions and improved life quality (Bedra et al 2013). Sufferers should have access to a wide range of skills available from the multidisciplinary team. Those include exacerbation limitation, respiratory failure, chronic productive cough and anxiety and depression.
Patients discharged from hospital are susceptible to readmission (Bedra et al 2013). Understanding the condition and knowing when they are having an exacerbation is imperative for self management, and what to do in the given circumstances, and when and what medication to take, or realise they need hospital treatment.
The main form of treatments comes from inhaled therapies and explained below would be when they would be administered and their understandings are a major factor in self management.
For breathlessness and exercise limitations: A short acting Beta2 agonist (as required) or short acting muscarinic antagonist (as required).
For exacerbations or persistent breathlessness: A long acting beta2 agonist, long acting muscarinic antagonist, to – long acting beta2 agonist + inhaled corticosteroid (Combination Inhaler) OR a long acting muscarinic antagonist (must discontinue short acting antagonist once this is commenced).
(Remember if using Corticosteroids, this has no evidence of long terms benefits).
If experiencing persistent exacerbations or breathlessness. Long acting Muscarinic antagonist + long acting beta2 agonist and inhaled corticosteroid (combined inhaler).
Niesters et al, (2012) describe how oxygen therapy can also be used, but awareness of inappropriate oxygen therapy with COPD patients is imperative as this can cause respiratory depression.
The British Thoracic Society (BTS) have identified five high impact actions that can improve outcomes for people being discharged after an acute exacerbation of COPD. The form is a quick way of identifying patients need for those interventions, ensuring their needs are met. The aim is for lessened hospital readmission rates with self monitoring patients. The five actions are;
Review of medication and demonstration of inhalers they will be using.
Provide a written Self Management plan and Emergency drug pack.
Asses and offer referral for smoking sensation.
Assess for suitability for pulmonary rehab.
Arrange a follow up call within 72 hours of discharge.
Reardon et al, (2005) explain pulmonary rehabilitation as programs which work with patients to help manage their condition, muscle strength, ability to cope with their disease, help with social requirements as people can become quite isolated.
Test includes incremental shuttle walk a 10 metre course, consecutive runs, each time getting faster, measured how far they got, will give idea of what they can endure on the exercise programme they can tale part in – all hoping to improve fitness and quality of life, breaking the cycle of not doing any exercise at home due to fear of becoming breathless, which will just be contributing to worsening of symptoms. The aim is to make the patient breathless, so they can teach them how to cope when they are having difficulty breathing at home. It also reduces the risk of heart attack, stroke, and diabetes.
Sufferers need to be aware that regular exercise at home is important. They need to look at their lifestyle, and stay as healthy and positive minded as they can as this will help keep the illness at bay. Smoking is a min contributing factor in the disease and should be stopped. Nicotine replacement should be offered and information on groups such as smoking sensation.
Leaning outcome 2
Any deterioration in a patient’s condition is an extremely worrying and stressful time for all involved: Patent, families and nursing staff alike. It is at this time when families can extremely worried, upset and stressed with the situation and they will be looking at the staff, expecting superlative care for their loved ones, they will be watching and listening to everything the Nurse says and does.
Care planning must be put in place beforehand, with the views and opinions of the patient at the forefront of any decisions that will be made. How they want to be nursed, where they want to be nursed, and inventively where they want to die should all be decided beforehand.
The National Institute of Health (NICE) has guidelines in place named: Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. (NICE, 2009). This should be followed when decisions are made about the treatments that are to be used on patients – and also when treatment will be stopped when end of life approaching.
The topic of Concordance is related to this type of scenario. Concordance is not to comply or to adhere to something – it is a way of working together with people and should be seen as the ethical goal of everyone involved. It is imperative that shared decision making is used within the NHS and should be undertaken without question at all times. (Coulter & Collins, 2011).
Gaining an understanding of someone’s health beliefs is not always a priority for the nurse. Latter (2011) explains that periodically, the chain of though can be pointing in another direction and perhaps to real consideration is given to the patients beliefs.
Nevertheless, Stenner et al, (2011) clarify that regardless of the quantity of information the patient or family require, when it comes to the decision makings on treatments – the professional judgement of the nurse was preferred by the majority, but the fact that the nurse has explained the various treatments available and there is an understanding of them, gives the patient and family a feeling of inclusion and satisfaction that they know the best care is being given.
Although Nursing staff are not seen as qualified councillors, one aspect of their role they need to make in response to end of life care is to council the family, they will need and expect you to talk them through their grief, explain in detail what happening any why, and be there for them in whatever means necessary in the moment following the death of the patient. Meerabeau & Wright, (2011) describe the moment – life as that family know it, has changed dramatically, and will never be the same again. They may have known death was coming, but until the moment it happens that is when it hits them and they are suddenly confronted with the reality of the situation.
Leaning outcome 3
The Telehealth system was launched in the UK in 2008 as a way of caring for the increasing numbers of patients using the NHS. Targeted users were to be the likes of elderly patients and those with a long term condition irrelevant of their age. Rural
The Department of Health (2012) insist that if it is used properly the savings on the NHS budget are vast. Accident and Emergency admissions are lower, as are elective admissions. They also state that there has been a large drop in mortality rates in areas where the system has been implemented and is used efficiently.
Sanders et al, (2012) define Telehealth as an intervention which will ‘allow remote exchange of data’ and additional information between a patient and a healthcare professional assisting in the diagnosis and management of an individual’s health condition. Patients in remote areas of the UK and those with limited services nearby, as well as patients who have difficulty accessing their local services are already benefiting from the service.
Ekeland et al, (2010) undertook a study in order to calculate the effectiveness of the system. Results were extremely positive throughout, and it was proved to be very cost effective, user friendly and patient feedback was constructive and encouraging for the service.
A second study, by Wooton, (2011) looked at patients with various long term conditions: they included COPD, Pulmonary Disease, Asthma, Diabetes, Hypertension and Heart Failure. The study investigated the numbers of sufferers with each condition, the type of Telehealth interventions used – along with intervention timings and patient outcomes. End figures found that 99% of the outcomes were in approval of the service, all experiencing improved results from previous periods when the service had not been available. Outcomes of the study had been based on worsening, equivalent or improvement on before implementation of the service in their homes.
More commonly recognised is the NHS 24 service, incorporating the Scottish Centre for Telehealth and Telecare (SCTT), it is the national provider of telehealth services in Scotland. An alternative service form the previous emergency number (999), it is contact point for members of the public who are requiring medical assistance or just medical advice. Contact to the service can be made by telephone, online and even through digital television channels. (Johansen, 2012).
The online version of the service (nhsinform.co.uk) provides quality assured health information, it has a sister website specifically for care of the elderly queries, (careinfoscotland.co.uk). The main service is the telephone based system and has professionals available and ready to take your call and guide you through your query – saving you from an unnecessary trip to the doctor or even calling an ambulance through panic of not knowing what is wrong or what to do. Staff at the end of the phone includes nurse practitioners, health information providers, pharmacists, dental nursing staff, counsellors and self help coaches.
Staff provide a complete telephone triage and consultation review and undertake high level, on the spot decision making.
Leaning outcome 4 a
As a country the government recognises the need to improve the health of the population as well as save money, the National Health Service (NHS) is struggling to cope with the numbers that are already using it, people are living longer, illnesses that go with old age are becoming more common, there are insufficient funds to give To the NHS and it is already proving to be working at unacceptable levels. Health improvements need to made, improvement activities set up, primary and secondary tertiary prevention, delivered in health care – in the hope that a person or people will adopt and maintain a healthier lifestyle or even be aware and have an understanding of their health in general.
The challenges surrounding the deliverance of reliable and approachable high quality healthcare and recuperating the health of the population are linked with the high expectations expected from people, with most needing implementation of lifestyle changes, demographic change, the ageing population and the economic climate which goes hand in hand with financial constraints for the majority of the target users of the service. A report by Layard et al, 2006 recognised a twelve million pound loss of output through depression alone in UK. This is mirrored by the World Health Organisation (2010) have highlighted the importance of promoting mental health issues in order to connect with people – enabling them to realise the life changes and improvements they need to undertake to improve their health. Explained further National Institute for Health and Care Excellence (NICE) where they have included a model of stepped care for depression with related outcomes of getting fit and healthy.
The Marmot Review (2010) argues that inequalities in health are linked with inequalities in society; therefore the degree health inequality is indicative of ‘how far society has come.’ Inequalities in our society are numerically vast, and this alone is proving to be a hurdle within anticipatory care planning for those involved. The WHO initiative, Improving Access to Psychosocial Therapies (IAPD) (2008) illustrates how such policies, aimed at reducing health inequalities can be implemented. Whilst the health of the population as a whole is important and recognised, Specific areas in the country are seen as ‘target areas’ for initiatives, areas that are seen in society as poorer or deprived as usually statistically higher in ill health, both mentally and physically. Increased mortality rates are also linked to such areas. Layard et al (2006). The recognition for health implementation is worldwide and not specific to the UK, and the WHO describes similar execution problems which are linked to psychosocial issues. Links with material circumstances such as home owning, income average in specific areas, human genetics and family history surrounding attitudes to health and undertaking lifestyle changes.
The Healthcare Quality Strategy for NHS Scotland (2010), their ultimate was to deliver the highest quality healthcare services to the Scottish population ensuring that the NHS Scotland is recognised worldwide for its standards. Delivering the best care is at the centre of their values and has been described in Better Health Better Care.
Through taking action they expect to see calculable improvements in the key indicators of healthcare quality.
A project by the NHS Scotland called ‘Have a Heart Paisley’ undertook population screening for ascertainment, health advice and reviews with recommendations to specific programmes. Healthy eating, exercise classes and smoking sensation groups were all involved in recruiting.
This was developed from anticipatory care strategies that had been drawn up by the Health Service to try and improve the health of the people of Paisley – and stop them from becoming part of the statistics regarding sufferers of long term conditions. (Health Scotland 2007).
Watt, O’Donnell and Sridharan (2011) describe the philosophy of anticipatory care as going in conjunction with increased evidence and theory regarding the health condition of the population – government challenge to bring together the strengths of primary medical care and the improvement of health, health education as a whole. Anticipatory care continued and continues to evolve in the country. The health needs of the nation grow in par with the population numbers.
Leaning outcome 4 b
The holistic assessment of a patient, does not just take the patient and the given illness in to account. Investigating the bigger picture surrounding the patient is also taken into account – this includes their given circumstances, assessment, diagnosis, and incorporating as much about them into the plan as is possible. This would make it easier to identify any changes in a patient’s condition at any given time in the future.
Roper Logan and Tierney, (LRT) (2000) base their model on the five main concepts, lifespan, daily living, dependence / independence, influencing factors on daily living activities. The factors which influence our undertaking of daily living activities (psychological, sociocultural, biological, environmental and politico economic) are included as each one has specific influencing factors on how we undertake our daily living skills. (Roper, Logan & Tierney 1996). This model supports holistic assessment and care planning in anticipatory care. Williams (2015) explains that looking at the whole patient scenario is imperative – it follows the LRT model of nursing, she describes it as a practice centred theoretical model ‘grounded in realism and accessibility.’ The RLT model is used widely throughout the UK. It applies the nursing process – assessment, diagnosis, planning, intervention and evaluation, and is commonly used as a guide for the nurse when undertaking a holistic patient assessment that serves as a basis for care planning. (Williams 2015).
Roper, Logan and Tierney, (2000) Explain that lifespan is seen as a continuum. But, nevertheless in contrary to the dependence to dependence continuum the arrow is looking in only direction which given the meaning of going forward only – until we reach the end on life and die.
Barnett (2007) clarify that within a clinical environment, the LRT model is followed when investigating research questions regarding specific functional deficits observed in patients that are needing skilled nursing care. Details about the model being used this way are also given by Matter (2007) and strengthen the relationship between the LTR model and holistic assessment and care planning in nursing. When the given specialist areas are investigated and addressed fully, improved patient outcomes are met. This is not just in the acute setting but those at home living with LTC such as COPD also benefit from following the model. (Kara 2007).
In the academic setting the model supports nurses develop and test a hypothesis about outcomes of care with a nursing framework (Tierney 1998).
The inclusion of an established and methodical nursing focused conceptual model increased the number of goals, recommends that a holistic approach to patient centred care planning promotes more involvement in patient care. (Dalton, Farrell & De Souza, 2012).
BARNETT, M., 2007. Using a model in the assessment and management of COPD. J Common Health. 21 (11), pp4-10.
Bedra, M., McNabney, M,, Stiassny, D., Nicholas, J. & Finkelstein, J.,2013. Defining patient-centred characteristics of a tele rehabilitation system for patients with COPD. Health Technology Information. 190 (24), pp6.
BRITISH THORACIC SOCIETY, 2015. Working for Healthier Lungs [online]. BTS. [viewed 26th April 2016]. Available From: https://www.brit-thoracic.org.uk/clinical-information/copd/
COULTER, A. & COLLINS, A., 2011. Making shared decisions making a reality. No Decision about me, Without Me. London: Blackwell.
DALTON, C., FARREL, R. & DE-SOUZA., 2012. Patient inclusion in goal setting during early inpatient rehabilitation after acquired brain injury. Clinical Rehabilitation. 26 (2), pp165-173.
DEPARTMENT OF HEALTH, 2008. Access to Psychological Therapies, [online]. Department of Health. [viewed 26th April 2016]. Available from: https://www.gov.uk/guidance/improving-access-to-psychological-therapies-payment-an-introduction
GREEN, J. & TONES, K., 2010. Health Promotion Planning and Strategies. London: Sage.
HEALTH SCOTLAND, 2007. Have a Heart Paisley. [online]. Health Scotland. [viewed 26th April 2016]. Available From: http://www.healthscotland.com/keep-well/programmes/hahp.aspx
THE SCOTTISH GOVERNMENT, 2010. The Healthcare Quality Strategy for NHS Scotland, [online]. The Scottish Government. [viewed 26th April 2016]. Available from: http://www.gov.scot/resource/doc/311667/0098354.pdf
JOHANSEN, R. 2012. NHS 24: The role of the nurse consultant. British Journal of Mental Health Nursing. 1 (3), pp182-185.
KARA, M., 2007. Using the Roper, Logan and Tierney model in care of people with COPD. Journal of Clinical Nursing. 16 (7b), pp223-233.
LATTER, S., 2011. Evaluation of Nurse and Pharmacist Independent Prescribing. Health (San Fran cisco), London: Eprints Soton.
Layard, R., Clark, D., Bell, S., Knapp, M., Meacher, B., Priebe, S., Turnberg, L., Thornicroft, G. & Wright, B. 2006. The depression report; A new deal for depression and anxiety disorders. [online]. The Centre for Economic Performance’s Mental Health Policy Group, LSE. London. [viewed 26th April 2016]. Available from: http://eprints.lse.ac.uk/818/
Marmot Review, 2010. Fair Society, Healthy Lives: A Strategic review of Health Inequalities in England Post 2010 [online]. Institute of Health Equity, [viewed 26th April 2016]. Available from: http://www.instituteofhealthequity.org/media/press-releases/consultation-on-european-review
MATTER, I. 2011. Using the Roper, Logan and Tierney model in the management of traumatic brain injury in a critical care setting. Singapore Nursing Journal 38 (3), pp14-19.
McIvor, R., Tunks, M. & Todd., 2010. COPD. Clinical Evidence. 06 (1), pp1502.
MEERABEAU, L, & WRIGHT, K., 2011. Long Term Conditions: nursing care and management. West Sussex: Wiley Blackwell.
NATIONAL INSTITITE FORT HEALTH AND CLINICAL GUIDANCE, 2009. Medicines Adherence: Involving Patients in Decisions About Prescribed Medicines and Supporting Adherence, [online]. NICE, [viewed 26th April 2016].
Available from: https://www.nice.org.uk/guidance/cg76
NIESTERS, M., MAHAJAN, R, P., AARTS, L, & DAHAN, A., 2012. High inspired oxygen concentration further impairs opioid induced respiratory depression. British Journal of Anaesthesia. 110 (5), pp837-841.
REARDON, J., CASABURI, R., MORGAN, M., NICI, C, & ROCHESTER, C. 2005. Pulmonary rehabilitation for COPD. Respiratory Medicine. 99 (1), pp519-527.
ROPER, N., LOGAN, W, W, & TIERNEY, A J., 1996. The Elements of Nursing: A Model for Nursing Based on a Model of living. 4th ed. Edinburgh: Churchill Livingstone.
ROPER, N., LOGAN, W, W, & TIERNEY, A J., 2000. The Roper, Logan- Tierney Model of Nursing Based on Activities of Daily Living. Edinburgh: Elsevier.
SPENCER, R., & Barcomb, T., 2014. New Technologies in COPD Management, [online]. Springer science & business Media New York: http://download.springer.com.gcu.idm.oclc.org/static/pdf/728/art%253A10.1007%252Fs40138-014-0051-9.pdf?originUrl=http%3A%2F%2Flink.springer.com%2Farticle%2F10.1007%2Fs40138-014-0051-9&token2=exp=1461249936~acl=%2Fstatic%2Fpdf%2F728%2Fart%25253A10.1007%25252Fs40138-014-0051-9.pdf%3ForiginUrl%3Dhttp%253A%252F%252Flink.springer.com%252Farticle%252F10.1007%252Fs40138-014-0051-9*~hmac=f7abffa0117e7c4f43482de0107d91f0d2c9a159dc8944065402c922f94b6def
STENNER, K, L., COURTNEY, L. & CAREY, N., 2011. Consultations between nurse prescribers and patients with diabetes in primary care: a qualitative study of patients views. International Journal of Nursing Studies 48 pp34-46.
TIERNEY, A J., 2008. Nursing Models: extant or extinct? Journal of Advanced Nursing. 28 (1), pp77-85.
WATT, G., O’DONNELL, C. & SRIDHARAN, S., 2011. Building on Julian Tudor Hart’s example of anticipatory care. Primary Health Care & Development. 12 (1), pp3-10.
WORLD HEALTH ORGANISATION, 2015. Psychosocial Framework, [online]. World Health Organisation. [viewed 26th April 2016]. Available from: http://search.who.int/search?q=psychosocial+framework&ie=utf8&site=who&client=_en_r&proxystylesheet=_en_r&output=xml_no_dtd&oe=utf8&getfie