Evidence Based Practice in a Clinical Setting - Essay Example

Evidence Based Practice in a Clinical Setting Introduction Evidence- based practice emerged in the 1980s. During the period, an approach was developed that essentially sought to utilize scientific evidence in a bid to determine the best practice. At that time, the approach was referred to as evidence-based medicine. With time, physicians and clinicians began to recognise the value of incorporating scientific evidence in decision making. The term evidence-based medicine evolved into evidence-based practice (Beyea & Slattery, 2006). Evidence-based practice seeks to shift from the traditional approach of clinical practice that is grounded in clinical experience, pathophysiological rationale, and intuition to the evidence-based approach. The evidence-based practice paradigm combines clinical expertise, patient preferences and values, the surrounding clinical circumstances with integration of the best scientific evidence (Salmond, 2007). The purpose of this paper is to apply evidence-based practice to the case of a patient and develop an effective patient care plan In order to apply evidence-based practice effectively there is need for a critical evaluation of the patient’s health condition. It is also equally important that a thorough research be conducted by the health care provider (physician/nurse) in order to generate information that relates to best evidence practice (Bennett, & John, 2000). The research in most cases is conducted in absence of already established guidelines that are grounded on previous research and are used for purposes of integrating evidence-based practice into everyday clinical practice. It is this information that will be integrated with the clinician’s expertise, patient preferences and values and the surrounding circumstances to develop a patient care plan that will optimize the outcomes and result in delivery of quality healthcare service (Schulman, 2008). Patient Profile The patient in this case is a 51 year old male computer programmer who is mildly obese. Patient has a history of smoking and has been trying to quit for over 30 years. He has tried using nicotine patches to help him quit smoking but was unsuccessful. Patient is reluctant to use Bupropion because he holds certain reservations against that particular group of drugs (antidepressants). No diabetic complications with controlled blood sugar levels. Patient has osteoarthritis on both knees which habour sporting injuries. The blood pressure according to the past two visits is mildly elevated (160/94 mmHG). Patient takes large doses of Vitamin E and Fish oil for his heart and glucosamine for his knees. Patient takes St. Johns Wort to assist him stop smoking. Research It is of primary importance that the patient’s treatment goals be identified. The goals offer guidance on which areas need research promptly. The treatment goals for the patient include solving the patient’s smoking problem, understanding the patient’s mild hypertension and possible therapy, managing the obesity, and determining the best therapeutic approach that can be used to treat the patient’s osteoarthritis. The patient has a history of smoking that spans over 30years. Such a patient can be considered to be a heavy smoker. Many smokers have been associated with several failed attempts to quit smoking. This particular patient has tried the use of nicotine patches to assist him quit smoking but was unsuccessful. According to Stead, Perera, Bullen, Mant, and Lancaster (2008), the single purpose of nicotine replacement therapy is to ease the transition from smoking cigarettes to complete abstinence from smoking. The nicotine temporarily replaces the nicotine from cigarettes thereby reducing the motivation to smoke and the overall withdrawal symptoms that are associated with abstinence from smoking. Nicotine replacement therapy can take several forms which include skin patches, nasal sprays, chewing gums, lozenges/tablets, and inhalers. In the same study Stead, Perera, Bullen, Mant, and Lancaster (2008), concluded that all forms of nicotine replacement therapy increased the chances of a smoker to quit by 50 to 70% regardless of the setting. With this kind of success rate, additional efforts to help the patient quit smoking will surely serve only to increase the rate of success. The patient had tried using the patches before in an effort to quit smoking but failed. It would be beneficial to try and establish the reason behind this failure. Generally, the common position held by relevant literature is that a combination of pharmacotherapy with nonpharmacologic interventions optimizes support for smokers who are trying to quit (Niaura, 2008). Such nonpharmacologic interventions include use of self help programs, group and individual counseling (cognitive-behavioral approaches), telephone counseling, interventions by the healthcare provider, and exercise programs. There exist other methods that can be used to stop smoking. The use of laser has been around for more than thirty five years in European countries and Canada (Freedom Laser Therapy, 2003). Although there exists claims that the technology can stop smoking in under an hour, such methods lack concrete scientific backing. Currently, studies are ongoing that establish whether the laser technology promotes release of endorphins within the body. Endorphins essentially trigger a system in the body that causes a reduction in stress and a general increase in energy (Freedom Laser Therapy, 2003). This method works on principles that are similar to acupuncture. Acupuncture reduces tension, relaxes the body and increases circulation. Laser therapy uses low powered laser on energy points that are related to addiction. These areas include wrist, face, ears, and hands. In a study conducted by John, Meyer, Hanke, Volzke, and Schumann (2006), to determine the relationship between smoking, obesity and hypertension, it was discovered that higher blood pressure was common among the non smokers and former smokers than the current smokers. In a general population study of male aged 45 years and above, it was revealed that there was a higher systolic blood pressure among current smokers than the never and former smokers. On adjusting for body mass index and alcohol intake, an interaction was established between smoking status and body mass index with regard to systolic blood pressure. There is enough documented evidence proving that there is an increase in weight associated with the cessation to smoke (John, Meyer, Hanke, Volzke, & Schumann, 2006). Our patient currently smokes and it is possible that the mild obesity he has may be a factor of his lifestyle rather than smoking. The obesity could also be the cause of the mild increase in blood pressure. Therefore a need to gain more insight on the patient’s lifestyle may prove critical especially when designing a plan for care. The patient had been noted to be obese. Obesity simply put, is the accumulation of body fat. In order to assess obesity, the body mass index is utilized. The body mass index (weight in Kiligrams/height in meters squared). A body mass index that is in excess of the 95 percentile is indicative of an obese individual (Proietto, & Baur, 2004). Evidence based approaches that can be used to manage obesity include counseling, screening, and medication. Obesity has been associated with causing or exacerbating a huge number of health problems. This it does either in association with other present diseases or by itself. Specifically, obesity has been closely associated with type two diabetes development, an increase in incidence of certain cancer forms, osteoarthritis of both the small and large joints and coronary heart disease, and obstructive sleep apnoea (Kopelman, & Grace, 2004). The patient has only had a mild hypertension in two past visits. It is therefore early to conclude that this hypertension could be linked to the obesity. Obesity has also been associated with osteoarthritis. Osteoarthritis is a degenerative disorder which has a multifactorial aetiology. It is a chronic condition that is characterised by periarticular bone remodeling and loss of cartilage on the articular surface. It is a condition that is associated with joint pain, and worsens with increasing weight bearing (Grainger, & Cicuttini, 2004). In managing osteoarthritis, a combination of both nonpharmacological and pharmacological approach delivers the best possible outcome. It is important that the patient accesses nonpharmacological programs like exercise programs and the Arthritis self management programs. The chemotherapeutic approach includes the use of drugs like paracetamol (as a first line of defense). If unsuccessful, non-steroidal anti-inflammatory drugs are used as the second line analgesics. The use of these drugs is subject to cardiovascular risk assessment. The patient’s use of glucosamine for the osteoarthritis should be encouraged as it has been shown that glucosamine is an effective drug. If all the above fails there may be need to use the invasive methods which include intra-articular therapies (Grainger, & Cicuttini, 2004). In order for the best outcomes of the patient’s intervention and care plan to be realized, effective communication is essential. There is overwhelming evidence that good physician/nurse-patient communication has the ability to improve the overall outcome of a patient’s treatment plan. Today, patients are considered to be health services consumers. There is an increasing demand by patients to be informed on their conditions. They want to be involved in every step of decision making and therefore it is of great importance that there is a good communication pathway between the doctor/nurse and the patient if the evidence based strategies are to work. In a study conducted by Mery (1998), revealed that doctors who communicated poorly were often abandoned for doctors who communicated well. With reference to evidence- based practice, it is worth noting that the differences that exist between the patients and doctors on what constitutes effective communication, has an impact on patient education and compliance and the general health outcomes (Mery, 1998). There are several studies that have been conducted to determine the association between patient outcomes and good communication. These studies came to a similar conclusion. The studies concluded that there is a correlation between the patient outcomes and effective communication. Many studies have also found that that there are positive associations between the communication skills of a doctor and the satisfaction of a patient (Mery, 1998). It is then vital that an effective communication channel is established between the patient and the medical practitioner (nurse/physician). It is through this channel that the patient will be introduced to evidence-based practice, and will be advised on any important issues relating to his well being (Stewart, 1995). Communication The outcomes of the application of evidence-based practice will to some extent rely on the effectiveness of the communication. The Accredited Council for Graduate Medical Education has developed a list of five key areas that a physician should be competent in so as to be able to communicate effectively with the patient (Traveline, Ruchinskas, & D’Alonzo, 2005). They include listening effectively, using effective questioning to elicit information, using effective explanatory skills in order to inform the patient, educating and counseling the patients and making decisions that are informed and are grounded on patient information and preferences (Traveline, Ruchinskas, & D’Alonzo, 2005). Before I introduce evidence-based practice to the patient, I will seek to find out what he knows about the topic. This will simply be achieved by asking the patient to inform me of any information that he may have on evidence-based practice. There is a possibility that other medical practitioners have already communicated to the patient some information about evidence-based practice. Based on his response it would then be possible to decide on the extent of information that relates to evidence-based practice that will be divulged to the patient to avoid creating more confusion. It is also of equal importance to establish what the patient wants to know. With this in mind it is possible to decide on the amount of information that can be availed to the patient. There are studies that have categorised patients on a range of information starting from those who need very little information to those with a need for details (Traveline, Ruchinskas, & D’Alonzo, 2005). As the discussion with the patient unfolds it will be possible to determine the amount of information that the patient seeks. It is during this discussion with the patient with regard to his health status that evidence based practice will be introduced and any advice given. While discussing with the patient, I will be empathetic with him. This will enable the patient note that I care about his emotions, but will help achieve patient satisfaction that is critical for the patient care plan to succeed. The discussion with the patient will be discussed in a slow manner with the necessary pauses allowing the patient time to comprehend the information and formulate any questions. This will allow the patient to develop a deep understanding of evidence-based practice that I will have introduced in addition to the advice that I will offer him. The discussions will be kept simple in order to enhance the patient’s ability to understand. I will use shot statements which are clear and also explanations that are easy to understand and clear. Giving the patient information that is tailored to his situation will not only reduce his level of stress but will also improve comprehension (Traveline, Ruchinskas, & D’Alonzo, 2005). Use of jargon during the discussion will be avoided as it will deter or prevent the patient from gaining a deeper understanding. The information that will be delivered to the patient will be as truthful as possible. It is important that the patient is given information that truly represents his situation and any potential dangers that he faces due to the actions that he takes. The patient will be adviced on the potential impact of his behavior on his health status. It may be necessary that certain aspects of his behavior change especially with regard to the obesity. I will watch out for patient reaction during the discussion. This will offer guidance on the areas of the discussion that may be in need of further elaboration or areas that are sensitive and need understanding and empathy while tackling them. The discussions will be held on predetermined days and time on a regular basis in order to monitor the progress of the patient and make nay necessary adjustments. Apart from the face to face discussion that I will be holding with the patient, there will be other forms of communication. This includes use of electronic mail, fax and telephones. Telephones will be of great value when it comes to providing timely advice to the patient while he is away from the hospital. I will encourage the patient to seek for clarification whenever he encounters any difficulty associated with his health. For instance the patient may come across certain information online that may be offering advice on a certain condition related to his health. It will be necessary that the patient gets in touch with me before executing the said advice. During our interactions, either face to face or via the other forms of communication, I will make it a point to offer educative material to the patient. This material could be in the form of articles in journals medical magazines, brochures with educative information, internet sites etc. This information will act as a guide that the patient can always use as a guide in decision making. He can use this information to make informed decision with regard to his health. Patient centered care plan Today’s patients have access to information regarding their diseases and options for treatment. This information helps the patients to make more informed decisions. With these imminent changes occurring in the healthcare industry, healthcare has been gravitating away from the traditional disease-centered model to a model that is patient centered. In the older model, physicians and nurses make almost all of the decisions. These decisions are based on data obtained from various medical tests conducted and their clinical experience. In the patient-centered model, patients take an active role and participate in their care and in the process the receive advice and more importantly tailor made services that fit their individual preferences and needs (U.S Department of Health & Human Services, May 2002). It is important that the physician/nurse establishes good patient relationships. With the good relationships, the patient will trust their physician/nurse and will be more likely adhere to the advice and treatment plans. It is important that the doctor listens to the patient and makes inquiries as this will reveal the true patient goals and needs (Pawar, 2005). Having thoroughly assessed the patient and obtained vital information with regard to his state of health, the problems of the patient are noted. The problems include: Mild obesity Mild hypertension Osteoathritis Inability to quit smoking The nursing diagnosis would then be Mild obesity Mild hypertension Osteoathritis Inability to quit smoking The goals of the plan include: To manage the obesity To manage the hypertension To manage the osteoarthritis Quit smoking Patient needs include Improving the level of health Alleviating pain Living a healthier life Better physical function Based on the research conducted an informed patient centered care plan can be developed. It was noted that for over 30 years the patient has been trying to quit smoking. Current evidence is that a combination of both pharmacological and nonpharmacological approaches in order to quit smoking. The patient has tried using the nicotine patches before and failed. During the discussions, after introducing evidence based practice concept to the patient, I will seek to explain to the patient the importance of using a combination nicotine replacement therapy. It would also be prudent to establish what the patient feels about the nicotine replacement therapy and why he thinks it failed. The nonpharmacologic approach will include making use of self help programs; cognitive behavioral approaches, exercise programs and telephone counseling. The self help programs are highly beneficial to the patient. The patient is given self help material that would motivate them to stop smoking and give them an actual guide which they can follow in order to quit smoking. These self help materials act as a reference point for the patient and are customized to the patient. Through active discussion with the patient, the patient can participate in designing the materials to suite his own needs. In such a case, the patient is likely to follow through with the plan (Niaura, 2008). The plan will also include use of telephones to counsel the patient. Telephones have been found to increase the rates at which people quit smoking. In yet another study, it was revealed that telephone counseling resulted in an increase in the use of programs and therapy sessions that are aimed at quitting smoking (Naiura, 2008). This serves to demonstrate the importance of telephones counseling. During the telephone sessions, the patient will be free to ask any questions and advice will be given accordingly. The telephone calls would also allow me to easily follow up on the progress of the patient. The cognitive behavioral therapy will include both individual and group therapy. The patient will be counseled individually and in a group. The patient stands to gain from the experiences of other smokers who are trying to quit and therefore enrolling the patient in a group that is trying to quit may potentially have desirable outcomes. Although there is lack of concrete evidence with regard to the benefits that arise from engaging in exercise for smokers trying to quit, it is pertinent to note that cases of improved success rates with inclusion of exercise in the plan of smokers who are trying to quit have been reported (Niaura, 2008). In order to manage the obesity, the plan has to include suitable strategies. The study that was conducted to define the relationship between smoking, obesity and hypertension revealed that an increase in weight occurred in individuals who had quit smoking or were non smokers. It can therefore be concluded that the obesity of the patient may not be associated with the smoking but other factors that include lifestyle. Obesity has been closely associated with development of heart disease, hypertension, osteoarthritis, cancer, sleep apnea, hyperlipidemia and stroke (U.S Department of Health &Human Services, 2004). In an effort to utilize an evidence-based practice approach such strategies like screening, medication, and counseling can be used. Screening will help assess the patient’s and will be used in every visit to assess for progress made in managing obesity. But because the patient has mild obesity it is preferable to advice the patient on the importance of exercise and healthy diets in managing obesity. The wife in this case would be the most suitable person to address. This information will be communicated during the discussion period and the patient and wife (if present) allowed to ask questions. The patient will be given educative brochures that contain healthy food available and how to combine the food in order to gain optimally from the food. The brochures will also contain information with regards to exercise routine suitable for his age that will have a potential of improving his overall health. The patient will be expected to read the manual and select the most appropriate food, and exercise routines. If they feel a need for a tailor made exercise routine, then through the discussion forum it will be possible to create one. The patient role in this case is to make an effort and eat the right kind of food and perform the right kind of exercise. The progress of the patient will be monitored continuously through telephone and other forms of correspondence. The patient may also call in to request for any clarification. Osteoarthritis has been noted as the most common form of arthritis in U.S. More than 20 million adults have been affected (U.S Department of Health & Human Services, 2002). It is a chronic condition that requires a multi-dimensional approach in its management. The plan will include both pharmacologic and nonpharmacologic approaches. The patient will be encouraged to exercise as he stands to gain a lot from it (Gainger, & Cicuttini, 2004). Exercising will allow him to reduce his weight thereby reducing the weight bearing problem associated with osteoarthritis. The weight control program will be beneficial in the management of obesity. All the options available will be discussed with the patient at length and room for questions will be given. Medical management will include the use of oral analgesics like acetaminophen initially, in conjunction with topical therapy. After patient monitoring and progress evaluation, if it is established that not much progress has been made, then, other medical approaches will be employed. These include intra-articular injection of products that have similar properties to hyaluronic acid into the joints, and surgery as a last resort. The patient will be educated on the importance of continuing with the exercise routine as exercise will have a great impact on the outcomes of the care plan. During the discussions the patient will be educated on the risks and benefits associated with each available plan of treatment. For instance, with the use of non steroidal anti-inflammatory drugs as sources of pain relief and the negative effect they have on the gastrointestinal tract (ulcers in stomachs). The patient will also be given access to important information regarding osteoarthritis so that he can make sound decisions with regard to his health and overall well being (National Institute of Health and Clinical Excellence, 2008). Because the hypertension has only been observed for two sessions initiating any form of chemotherapeutic intervention at around this time will be an early intervention. It is advisable that the patient be observed for at least three months; estimating within person variability of blood pressure and averaging the blood pressure will increase the accuracy of current practice (Benediktsson, & Padfield, 2003). In conclusion, it important that the patient is involved in the whole decision making process and his views be incorporated into the treatment plan. Equally important is the integration of evidence-base practice into the care plan in order to achieve the best outcome. Patient education and access to vital self help resources is of equal importance to the success of the care plan. The patient is to be continuously monitored and evaluated for progress and the care plan adjusted in light of the patient’s status at time of examination. All the necessary changes deemed necessary are effected at that time in order to optimize the outcome. References Agency for Healthcare Research and Quality. (2002). Managing osteoarthritis: Helping the elderly maintain function and mobility. (AHRQ Publication No. 02-0023). Washington, DC: U.S. Government Printing Office. Agency for Healthcare Research and Quality. (2004). Managing obesity: A clinician’s Aid.( AHRQ Publication No. 04-0082). Washington, DC: U.S. Government Printing Office. Agency for Healthcare Research and Quality. (May 2002). Expanding patient –centered care to empower patient’s and assist providers. (AHRQ Publication No. 02-0024).Washington, DC: U.S. Government Printing Office. Baur, L.A., & Proietto, J. (2004). Management of obesity. The Medical Journal of Australia, 180(9), 474-480. Benedicksson, R., & Padfield, P.L. (2003). Maximizing the benefits of treatment in mild hypertension : Three simple steps to improve diagnostic accuracy. Quarterly Journal of Medicine, 97(1), 15-20. Bennett, S., & John, W.B.(2000). The process of evidence-based practice in occupational therapy: Informing clinical decisions. Australian Occupational Therapy Journal, 47, 171-180. Beyea, S.C., & Slattery, M.J. (2006). Evidence-based practice in nursing: A guide to successful implementation. Retrieved from: http://www.hcmarketplace.com/supplemental/3737_browse.pdf Freedom Laser Therapy, Inc. (2003). How Quit smoking laser therapy works. Retrieved from: http://www.freedomlasertherapy.com/how_laser_therapy_works.htm Freedom Laser Therapy, Inc. (2003). Freedom laser therapy smoking addiction. Retrieved from: http://www.freedomlasertherapy.com/ Grainger, R., & Cicuttini, F.M. (2004).medical management of osteoarthritis of the knees and hip joint. Medical Journal of Australia, 180(5), 232-236. John, U., Meyer, C., Hanke, M., Volzke, H., & Schumann, A. (2006). Smoking status, obesity and hypertension in a general population sample: A cross-sectional study. Quarterly Journal of Medicine, 99, 407-415. Kopelman, P.G., & Grace, C. (2004). New thoughts on managing obesity. Journal of Gastroenterology and Hepatology, 53(7), 1044-1053. Meryn, S. (1998). Improving doctor-patient communication: Not an option but a necessity. British Medical Journal, 316(7149), 1922-1930. National Institute for Health and Clinical Excellence.(2008). Osteoarthritis: The care and management of osteoarthritis in adults. Retrieved from: http://www.nice.org.uk/nicemedia/pdf/CG59NICEguideline.pdf Niaura, R. (2008). Nonpharmacologic therapy for smoking cessation: Characteristics and efficiency of current approaches. The American Journal Of Medicine, 121(4A), S11-S19. Salmond, S.W. (2007).Advancing evidence-based practice. Orthopaedic Nursing, 26(2), 114-123. Schulman, C.S. (2008). Strategies for starting a successful evidence-based practice program. Advanced Critical Care, 19(3), 301-311. Stead, L.F, Perera, R., Bullen, C., Mant, D., & Lancaster, T. (2007). Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews, issue 1. DOI: 10.1002/14651858.CD000146.pub3. Stewart, M.A. (1995). Effective physician-patient communication and health outcomes: A review. Canadian Medical Association Journal, 152(9), 1423-1433. Travaline, J.M., Ruchinskas, R., D’Alonzo (2005). Patient-physician communication: Why and how. The Journal of the American Osteopathic Association, 105(1), 13-18. Read More