Respiratory Disease Management in Primary Care Reflective Nursing Model - Case Study Example

Respiratory Disease Management in Primary Care Reflective Nursing Model Part I: of the event The case study involves a 3 year old girl diagnosed with asthma who suffered a serious episode requiring hospitalisation for 2 days. I met the patient and her family at the time of hospital discharge. Though the child was doing well at the time of discharge, her parents were extremely distraught and frightened of a reoccurrence. The child had been recently diagnosed with asthma and this was her first hospitalisation following a severe attack of wheezing and cyanosis. The parents were afraid that their young child would die. The child’s chart indicated that the child’s asthmatic episodes were frequently associated with viral infections, whose occurrence is difficult to avoid in young children. The child was given preventive and rescue medications according to standard treatment protocol should an episode occur. The pulmonologist did her best to reassure the parents, but the fact that there was no clear prognosis regarding future episodes and their potential severity made me more aware of the complex nature of this disease and its physiological and psychological impact on the patient and the family. The absence of concrete treatment and prevention guidelines was a matter of personal concern. Part II: Personal feelings This incident was very disturbing as it involved a young child with a severe respiratory condition that was somewhat unstable. Before this incident, I considered asthma to be a serious, chronic disease, but this practice event made me more aware of the unpredictability of the disease and the difficulties that may be encountered in care management. I realized for the first time the tremendous psychological effect that this disease has on the family members which compounds the physiological condition. I felt that in order to care for patients in a primary care setting with acute respiratory distress associated with asthma I needed to understand better the physiological effects of the disease, the important areas for prevention and treatment and the psychological factors that affect both patient and family members in the wake of this chronic disease. Part III. Evaluation In evaluating this experience, I realized that effective primary care management of patients with breathing disorders requires a broad-based knowledge of diverse areas, including the complex nature of breathing disorders such as asthma, the importance of patient follow-up to ensure effective ongoing care management, the importance of family support and involvement in the care management process. These complex issues require assessment from both a medical and psychological perspective. Clearly, these issues need to be addressed to determine how best to reduce the need for hospitalisation of children with asthma and to prevent the confusion and anxiety experienced by the parents of the child with asthma I encountered in clinic. From a clinical standpoint, early diagnosis and early intervention to control symptoms and prevent acute attacks are essential components of asthma care management. Asthma is a chronic respiratory disease that may be confused symptomatically with COPD, but can be distinguished by several important diagnostic criteria (Carljford & Lindberg 2008). Episodes of coughing and wheezing are among the first recognisable symptoms of asthma, which typically has an early age of onset in childhood or adolescence. Asthma is clinically distinguishable in this way from COPD which generally develops later in life, often as a consequence of cigarette smoking. Asthma attacks frequently occur in response to environmental triggers such as allergens of exercise, whereas COPD is exacerbated by lung infections. In contrast to patients with COPD, who generally endure daily symptoms, the proper care and management of patients with asthma should render these patients symptom-free in many cases (Carlfjord & Lindberg 2008). Successful management of asthma is defined by the following parameters: Absence of daytime symptoms Undisturbed sleep No rescue medication required No limitations on activity Normal lung function In order to achieve control, standard of care recommendations are: Early treatment of symptoms with medication. Early control of disease. Maintain control by effective monitoring of symptoms and medication adjustment as needed. Medication step down when stable control is achieved. Part IV. Analysis The multi-faceted medical and psychological issues surrounding the care of patients with asthma have been the focus of important international research studies that have provided important recommendations for primary care management. The National Institute for Health and Clinical Excellence (NICE) has published a series of guidelines for the treatment of children with asthma (NICE 2002). These guidelines indicate that young children (under 5) whose asthma is stable should be given both corticosteroids and bronchodilator therapy administered via Pressurised Metered Dose Inhaler (PMDI) along with a spacer system. A facemask may be required for effective delivery. If this treatment protocol is not sufficient to prevent breakthrough attacks, nebulised therapy may be used in some children between the ages of 3 and 5 years. Alternatively, a dry powder inhaler (DPI) may be administered. NICE guidelines further stress that asthma is a complex disease, requiring a multi-faceted therapeutic approach. First line treatment of severe asthma generally involves the administration of inhaled B2 agonists. The early addition of intravenous salbutamol to the treatment protocol may be a useful adjunct in severe asthma cases. Prednisolone should be administered immediately to treat acute asthma attacks. The generally approved medication is inhaled steroid (beclometasone BDP) administered via metered dose inhalers. The current recommendations are that the patients should be maintained at the lowest possible dose of medications, due to significant potential side effects. Patients should be evaluated every 3 months for possible step-down and the decreases in medication should range from 25-50% at one time to achieve a gradual reduction (Castro et al 2003). Diagnostic standards for the classification of severe asthma include the following symptoms: Hypotension Silent chest Exhaustion Cyanosis Poor respiratory effort. These symptoms require immediate medical attention Children with severe acute asthma displaying the above symptoms require hospitalisation to reduce the risk of life-threatening complications. Standard of care generally involves the administration of nebulised B2 agonists (salbutamol or turbutaline) (Brand 2003). Children in primary care who do not respond after 10 puffs of B2 agonist should be hospitalised. Moreover, serious cases require high flow oxygen administration with face mask or nasal cannula. Additional research studies have focused on identifying preventive strategies for asthma management. Current evidence suggests that non-pharmacologic management of asthma may have limited effectiveness in controlling the disease (Brand 2003). For example, avoidance of potential allergens, nutritional supplements and other non-pharmacologic interventions has not produced consistent, reliable evidence for reducing the incidence or severity of asthmatic attacks (Cullum 2001). The exception is smoking. There is significant evidence that prenatal exposure to cigarette toxins and exposure to cigarette smoke may increase the likelihood that a child will develop asthma and increase the severity of disease (Tonnensen et al 2005). Another potentially important area of non-pharmacologic intervention involves the importance of obesity as a contributing factor in the disease. Much research suggests that individuals with breathing disorders such as asthma or COPD are at high risk for anxiety and depression (Kamps et al 2003). The psychological impact can be disabling, as patients may suffer anticipatory anxiety over the prospects of recurring episodes. The inability to breathe easily may also trigger anxiety and even panic attacks in patients experiencing acute respiratory episodes. These emotional responses can impact the medical condition as well as contribute to chronic depression that dramatically affects the quality of life. Moreover, anti-depressant medications may sometimes have adverse effects on respiratory status, so these should be administered judiciously to patients with breathing disorders and clearly are not a panacea for dealing with the psychological issues associated with attempting to adjust to chronic lung disease (Kamps et al 2004). Research studies conducted by the Childhood Asthma Management Program (CAMP) involved a randomized clinical trial of over 1000 families whose children suffered from mild to moderate asthma (Bender et al 2000). Psychological questionnaires addressed parameters such as anxiety, depression, family support, social support and behaviour. The study suggested that children coping with asthma experience moderate adjustments to their daily lives in dealing with health-related issues; however, the psychological health of these children was generally excellent in cases where the family scored high on the Impact on Family Scale, which measures the overall adaptation of the family to the child’s medical condition. Research studies conducted in several European countries by the Global initiative for Asthma (GINA) indicated that parents of children with asthma are often unprepared to handle important care management issues critical to the physical and emotional well-being of their children (Stevens et al 2002). This study found that approximately 25% of the 631 parents surveyed did not understand the difference between medications designed to treat acute asthmatic attacks and those medications designed to prevent attacks. Even more disturbing, the researchers discovered that almost 50% of children diagnosed with chronic asthma do not take their controller medication on a daily basis. This was one of the first studies to address the psychological and social impact of asthma in children on their families. The study indicated that greater than 40% of families experienced high degrees of stress in coping with this disease (Stevens et al 2002). Part V. Conclusion (Synthesis) Analysis of recent research in primary care management of breathing disorders such as asthma has shed much light on my professional encounter with a patient with unstable acute asthma requiring hospitalisation (Nathan et al 2006). One important conclusion from these research studies is that parents need to be better trained to recognize serious symptoms in children with asthma that require immediate medical attention. Moreover, in difficult cases of childhood asthma, family therapy is highly recommended as an adjunct to pharmacotherapy in the management of the disease. Despite the anxiety experienced by many parents caring for a child with breathing disorders such as asthma, recent research suggests that a significant percentage are poorly informed regarding the basic aspects of care. It is clear that parents and other caregivers should be given detailed instructions regarding management of the care of an asthmatic child. Such instruction may have calmed the anxiety of the parents I encountered in clinical care and given them more effective approaches to care management at home. These research findings demonstrate that improved family involvement in every aspect of care and management of children with breathing disorders is essential to stabilizing disease, preventing long-term medical consequences, and ensuring the psychological and emotional adjustment of children faced with the challenges of dealing with chronic lung disease. An important aspect of the management of chronic disease involves psychological adjustment and adaptation to the lifestyle and medical issues that may be confronted on an ongoing basis. Emotional and physical well-being are intricately linked aspects of overall health; research suggests that the emotional and psychological component of chronic breathing disorders is essential to effective clinical management. The CAMP research study (Bender et al 2000) concluded that the major factor associated with good psychological adjustment parameters in children with asthma was the overall psychological adjustment of the family in regard to the child’s chronic condition rather than the severity of the disease itself in individual cases. The results of the GINA study demonstrated that parents of children with breathing disorders are, in general, very poorly trained for the complex task of caring for a child with a chronic and, in some cases, potentially life-threatening disease (Massie et al 2004). Given that the incidence of asthma in children has reached the highest levels ever and has been termed a global “epidemic” by some clinicians, these findings paint a disturbing portrait of family ignorance in the face of this potentially devastating disease. It is not surprising then, that amidst this lack of information and confusion about essential care and management issues, anxiety, depression and poor family adjustment are commonly encountered in families dealing with childhood breathing disorders. In conclusion, my clinical case experience alerted me to the tremendous challenges involved in the care of children with chronic breathing disorders. In research, I have found that my experience was not unique, in that many families experience anxiety and great stress in dealing with acute episodes and chronic care management. I am more aware of the importance of a multifaceted, inclusive approach to primary care of patients with breathing disorders that involves not only well-trained healthcare personnel, but families and other caregivers who must be provided with the training to handle ongoing care and medical emergencies and the emotional support to handle the psychological adjustments to chronic care management. Part VI. Action Plan Many initiatives have been put forward to improve care management and psychological adjustment of children suffering from breathing disorders and their families. A “Living Guideline” proposed jointly by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN), these recommendations include the introduction of “Asthma Action Plans” to be given to patients and their families to assist in care management (NICE 2002). These written plans provide readable information in the format of a treatment plan individualised for the management of each patient. Another important issue addressed by these guidelines involved a call for specialized training asthma management for healthcare personnel involved in the primary care of patients with asthma. Pilot studies in this area indicated that these training programs have a very positive effect on facilitating better care delivery when clinicians are given supplemental training in this area. The areas of improved care management include: More accurate diagnosis better patient monitoring better continuity of care The guidelines advise that trained health professionals work closely with patients and their families to ensure continuity of care in the home. References Bender, B, Annett, R, Iklé, D, DuHamel, T, Rand, C & Strunk, R 2000, ‘Relationship between disease and psychological adaptation in children in the childhood asthma management program and their families’, Arch Pediatr Adolesc Med, pp. 706-713. Brand, P & Roorda, R 2003, Usefulness of monitoring lung function in asthma Arch. Dis. Child., vol. 88, no.11, pp. 1021 – 1025. Carlfjord , S & Lindberg , M 2008, Asthma and COPD in primary health care, quality according to national guidelines: a cross-sectional and a retrospective study, BMC Family Practice, vol. 9, no. 36, pp. 412-420. Castro, M, Zimmermann, N, Crocker, S, Bradley, J, Leven, C &. Schechtman, K 2003, Asthma Intervention Program Prevents Readmissions in High Healthcare Users, Am. J. Respir. Crit. Care Med., vol. 168 no. 9, pp. 1095 - 1099. Cullum, N 2001, Evaluation of studies of treatment or prevention interventions. Part 2: applying the results of studies to your patients Evid. Based Nurs., vol. 4, no.1, pp. 7 - 8. Kamps, A, Brand, P, Kimpen, J, Maille, A, Overgoor-van de Groes, A, van Helsdingen-Peek, L & Roorda, R 2003, Outpatient management of childhood asthma by paediatrician or asthma nurse: randomised controlled study with one year follow up, Thorax, vol. 58, no. 11, pp. 968 - 973. Kamps, A, Roorda, R, Kimpen, J, Overgoor-van de Groes, A, van Helsdingen-Peek, L & Brand, P 2004, Impact of nurse-led outpatient management of children with asthma on healthcare resource utilisation and costs, Eur. Respir. J., vol. 23, no. 2, pp. 304 - 309. Massie, J, Efron, D, Cerritelli, B, South, M, Powell, C, Haby, M, Gilbert, E, Vidmar, S, Carlin, J, & Robertson, C 2004, Implementation of evidence based guidelines for paediatric asthma management in a teaching hospital, Arch. Dis. Child., July 1, vol. 89, no. 7, 660 - 664. Nathan, J, Pearce, C, Field, Dotesio-Eyres, N, Sharples, L, Cafferty, R & Laroche, C 2006, A randomized controlled trial of follow-up of patients discharged From the hospital following acute asthma: best performed by specialist nurse or doctor? Chest, vol. 130, no. 1, pp. 51 - 57. National Institute for Clinical Excellence, 2002. Chronic obstructive pulmonary disease, Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Clinical Guideline 12. London: NICE. Stevens, C, Wesseldine, L, Couriel, J, Dyer, A, Osman, L & Silverman, M 2002, Parental education and guided self-management of asthma and wheezing in the pre-school child: a randomised controlled trial, Thorax, vol. 57, no. 1, pp. 39 - 44. Tonnensen, P, Pisinger, C, Hvidberg, S, Wennike, P, Bremann, L, Westin, Å, Thomsen, C & Nilsson 2005, Effects of smoking cessation and reduction in asthmatics, Nicotine Tab Research, vol. 7, no. 1, pp. 139-148. Tønnesen, P, Pisinger, C, Hvidberg, S, Wennike, P, Bremann, L, Westin, Å, Thomsen, C & Nilsson, F 2005, Effects of smoking cessation and reduction in asthmatics. Tønnesen, P, Pisinger, C, Hvidberg, S, Wennike, P, Bremann, L, Westin, Å, Thomsen, C & Nilsson, F 2005, Effects of smoking cessation and reduction in asthmatics. Nicotine Tob Research, vol. 7, no. 1, pp. 139-148. Read More