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Chronic And Complex Nursing Care

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Question:

Discuss about the Chronic and Complex Nursing Care.
 
 

Answer:

Introduction

Nursing practice in regard to care for patients with chronic and/or complex conditions requires different guiding principles. The principles are particularly put in place to guide different aspects to be addressed in the design of a nursing plan for the patients. These principles are not only paramount in ensuring proper patient care but also inform decision making for criticize care multi-disciplinary team members, the patient and their family members. In this regard, it is apparent that nursing plans be in line with set guiding principles. The principles include the need for: healthcare and support; teaching and coaching; advocacy and co-ordination and; education, research and evaluation.  The guiding principles above are thus the main framework upon which patient care is centered while within the critical care unit until the patient returns to  a stable condition within the hospital and at home after discharge. In this discussion, there is a deeper explanation of these guidelines in terms of their importance in the development of nursing care plans within chronic and/or complex care units, including an examination of the approaches to be used in the improvement of a patient’s health outcomes. This presentation will also highlight the specific nursing plan necessary for the patient in the case study, who reportedly diagnosed of COPD exacerbations. Even further, the discussion will focus on establishing possible situations where a nurse can obtain opportunities for collaborating with members of a given interdisciplinary team assigned to the patient within the critical care unit.  

 

The Guiding Principles in Planning Nursing Care for Patients with Chronic and Complex Conditions

  1. Health Care and Support

Under this guideline, a registered nurse has the sole responsibility to engage the interdisciplinary team to facilitate the provision of required care and support to a patient with complex and chronic condition. In the hospital setting, the nurse should ensure that the patient is diagnosed for any given body conditions which require attention and also to inform decision making on additional treatment of the conditions (Straughair, 2011). Under healthcare and support, the interdisciplinary team under the nurse focuses on managing breathing inefficiency, imbalanced nutritional status, proper positioning, and on administration of required medications. In regard to support, the nursing plan must comprise of different approaches of enabling the patient to manage themselves and independently move, eat, or groom (Elder, 2017). The team thus avails the necessary support to ensure that in the short or long-run, the patient with a complex and/or chronic condition is comfortable in the hospital or home environment. There is also need for environmental modifications to ensure that the patient is position to cope with the condition, minimize pain and avoid factors that aggravate the condition and or trigger its acute situation (Straughair, 2011). Healthcare and support thus involves specific approaches depending on the condition and age of the patient, but is a core requirement evidence-based practice.

  1. Teaching and Coaching

Considering the guideline for the need for teaching and coaching, Registered Nurses have the responsibility to educate the patient, care takers and family; to be able to independently control their own health (Straughair, 2011). The nurse identifies presents the required educational needs including responses to specific requested information by the patients and/or clients. For a case of COPD management as is the case for Angela, the nurse should provide teaching and coaching materials for self-management to prevent exacerbations (Sciarra, 2012). These educational and coaching sessions can be formal and informal depending on the convenience of the patients and/or clients. The nurse can focus on in teaching and coaching on hygiene, patient movement and/or exercise, meal-time management, required medication, sexuality, death, dying and chronic sorrow (Sonola et al, 2013).  While the teaching and coaching sessions can be formally done in sessions, nurses can identify special “teaching moment’s each day and pass this crucial information to the patients and family. Coaching and teaching of patients on the above areas help in promoting their own participation in their health well-being and reduce any risks associated with chronic and complex ailments.

 

  1. Advocacy and Co-ordination

Nursing practice emphasizes the need for a nurse to advocate for the rights of their patients and to coordinate the necessary nursing interventions required.   In regard to advocacy, nursing respects human rights which encompass cultural rights, a right to life, right to consent to treatment, individual dignity among others (Sonola et al, 2013). It calls for the need to; provide a safe and healthy environment; ensure equity and social justice while allocating resources and further; enhance accessibility of healthcare and socioeconomic services. For the benefit of the patients under care, the nurse should also identify and explain any policies and/or practices that infringe their rights. They should also explain the policies, necessary procedures and specific guidelines to be followed in case patients’ rights are compromised (Sciarra, 2012). Advocacy in nursing assures patients and families of quality, safe and ethical healthcare.

On coordination, nurses should collaborate with patient, their family, caretakers, the multidisciplinary health team, and the hospital management to offer quality healthcare. It is however important to understand the necessary guidance that each player might require in order to offer a quality nursing health intervention.  It is the nurse’ role to therefore ensure that there is a multidisciplinary continuity of care to ensure that the patient experiences care as both connected and coherent (Straughair, 2011).  Experience of continuity for a patient and their family is the perception that healthcare providers understand what occurred before, the different healthcare providers agree on certain management plan, and further that any of the providers that now knows them will provide care to them in the future.

  1. Education, Research and Evaluation

Evidence-based nursing practice requires that the knowledge underpinning different approaches in nursing intervention be questioned.  On education, the nurse needs to take part in continuing professional development programs to be abreast with the latest information, research, guidelines on care for patients with chronic and complex health conditions (Straughair, 2011). The nurse requires to have actively participated in this evidence-based practice professional development by presenting their individual experiences. They can also take part in short refresher courses offered online by different medical institutions, to sharpen their skills in interventions on managing chronic and complex complications.

On research, nurses should take part in research studies especially on the required nursing care plan for individuals with chronic and complex diseases.  They can do so by reading and utilizing existing research in evidence-based clinical practice, participating in relevant research projects, and be leaders in research projects after identifying any gap in nursing practice (Sonola et al, 2013). The nurse can thus rely on already existing online research database in Australia to extract information on research in chronic and complex care. These include the Cochrane Library, Google Scholar among others. Information acquired from research is important as it helps in informing the nurse’s decision making on nursing care plan and coordination of the constituted inter-disciplinary team.

Evaluation involves setting and monitoring an individual’s health goals, clinical governance aspects and use of reflective practice. A nurse should identify patient’s measurable goals, including those of their caretaker and the multidisciplinary nursing team to determine whether they are achieved. Clinical governance as part of evaluation requires that clinicians and/or administrators participate in joint action to ensure that quality of care. Lastly, reflective practice requires the nurse to engage themselves in continuous critical evaluation when alone, through journals, research articles and even under a special clinical supervisor. This helps them to improve healthcare quality and to have a stimulated professional growth.

 

The role of the registered nurse, Nursing Plan & appropriate Nursing Interventions for a COPD Patient

  1. Solving Knowledge Deficiency

This nursing plan focuses on increasing the patient’s and their family’s cognitive information on COPD. It is thus in line with the guiding principle of the need for teaching and coaching (Cramm & Nieboer, 2013). Knowledge deficiency can be evidenced through request forms, misconceptions, poor instruction follow-through and a development of complications that are easily preventable. In this regard, the nurse should explain to the patient the disease process and reinforce these explanations for the message to sink. They should be allowed to ask questions and this reduces anxiety while boosting their willingness to participate in the nursing plan.  The patient should be instructed on the importance of breathing exercises, effective coughing among other conditioning exercises (Lau et al, 2017). This exercises increase respiration muscles strength, prevents collapsing of small airways while at the same time controlling dyspnea. The nurse should emphasize the need for dental and oral care to prevent any bacterial growth that could contribute to pulmonary infections. The triggering factors of COPD exacerbations and the need to avoid them should be explained (Elder, 2017). They include dry air, extreme temperatures, wind, tobacco, aerosol sprays, and pollen among others. The nurse should also instruct the patient on the dangers of smoking and advice the patient on cessation to slow and/or halt COPD progression. Teaching and coaching should also focus on the need for medical follow-up and encouraging regular sputum culture including necessity of chest x-rays. This is important in altering a patient’s therapeutic regimen. The patient should also be encouraged to take part in support groups to reduce anxiety and depression due to its therapeutic emotional support and/or respite care (Lau et al, 2017). There is need to discuss the side effects and/or adverse reactions related to each respiratory medication to inform change in regimen or continuity of a particular medication. Further, the nurse should instruct and reinforce information on inhaler medication and use to enable them self-manage when away from the hospital to control exacerbations.

  1. Managing Patient’s Imbalanced Nutrition

Imbalanced nutrition refers to a situation where the intake of food nutrients is insufficient in order to meet the patient’s metabolic requirements (Howard & Ceci, 2012). This agrees with the guideline; to provide healthcare and support to patients. Imbalanced nutrition can result from dyspnea and sputum production. It can also be caused medical side effects, vomiting, anorexia, fatigue and nausea. It can be managed first by confirming the whether the patient and caretaker understand the nutritional requirements so as to ascertain client informational needs (Cramm & Nieboer, 2013). Lack of information can then be addressed through the teaching and coaching guideline on nursing plans. The nurse can evaluate patient dietary habits and recent food intake and ascertain degree of their eating difficulty. Body weight and size evaluation can inform the dietician on how to stabilize the patient’s nutritional needs. Bowel auscultation should be done to understand whether there is decreased gastric motility which is an indicator of possible limited intake of fluids, hypoxemia and poor choice of food. The nurse should provide oral care and promptly remove expectorated secretions to prevent noxious tastes and smells from deterring patient appetite, trigger nausea and an increase in respiratory difficulty. A rest period of minimum 1 hour to mealtime should be allowed to decrease fatigue at meal time so that more calories can be taken up (Kuharic et al, 2015). The time may vary and the nurse can conform from research tools and any necessary additional directions they can take. Further, there is need for supplemental oxygen at meal time to reduce dyspnea and boosts energy for eating and thus enabling food intake.

  1. Managing Ineffective Airway Clearance

This involves enabling the COPD patient to clear any secretions and/or obstructions within the respiratory tract so that the airway remains clear (Ides et al, 2011). In this regard, the nurse should first auscultate the breath sounds to ascertain wheezing, rhonchi and crackles. Moist crackles will inform the need to treat patient for bronchitis while expiratory wheezes indicate that the patient has emphysema and should be treated accordingly (Chin, 2017). The patient should be assisted to assume a comfortable position with the head elevated to enable easy respiration. The arms or legs can be supported with pillows to minimize fatigue and enable expansion of the chest. Environmental pollution should be avoided to avoid triggering of acute COPD through exacerbations within the ward or at home (Cramm & Nieboer, 2013). The Registered Nurse should encourage the patient to use pursed-lip and abdominal breath exercises. This will help the patient to have coping means to dyspnea and also minimize air-trapping, a condition that is common in COPD. The characteristics of the patient’s cough should be examined as to whether it is persistent, moist, or hacking so that they can be assisted to improve coughing effort effectiveness.  This is necessary, understanding that cough could be persistent yet ineffective particularly among elderly patients as Angela. The patient should be assisted to take an upright and/or head-down posture after chest percussion has been done. Further, the patient should be provided with a minimum of 3000mL daily but within the patient’s cardiac tolerance (Cramm & Nieboer, 2013). Patient hydration assists in reducing secretion viscosity to aid expectoration.

 

Opportunities for Collaboration with the Inter-disciplinary Team and Coordination of Care

Understanding that COPD exacerbation presents with shortness of breath among patients, this is an opportunity for the nurse to collaborate with a respiratory therapist to ensure the patient gets enough air circulation. A respiratory therapist will help in solving the patient’s dyspnea and other respiratory healthcare problems the patient often goes through (Chin, 2017).  The therapist for instance will draw arterial blood gases, ensure the maintenance of patients with mechanical ventilation, and provide incentive spirometry, among other intermittent respiratory treatments. They can also give respiratory medications to patients, intubate them, and help in bronchoscopy (Jan, 2013). Further, the nurse will need a respiratory therapist to offer pulmonary hygiene services to COPD patients including chest physiotherapy. They also help in preventing and managing cardiac and/or respiratory arrests.

The second opportunity that calls for collaboration in the nursing plan for a patient with COPD exacerbation patient is at the point of meal-time management (Chin, 2017). The nurse will need to collaborate with a dietician within the interdisciplinary team to assess then plan, implement and later evaluate nursing interventions related to patient therapeutic dietary needs. At this opportunity, the dietician can educate the patient and family/caretaker on appropriate diet both in hospital and at home. Understanding that it is imperative for COPD patients to maintain healthy weight, as excess weight leads to more episodes of shortness of breath. On the other hand malnutrition among COPD patients leads to weakness and weakening of rib muscles that require energy for breathing (Jan, 2013). The nurse can thus involve the dietician to provide advice on calories needed to maintain breathing and keep the body muscles strong.

Further, the nurse can collaborate with an occupational therapist to manage the patient with COPD exacerbation at the point when the patient requires independent movement and functioning and thus picking on an occupational therapist (Cramm & Nieboer, 2013). The occupational therapist will thus assess the patient, plan, execute and evaluate any intervention provided in regard to those which facilitate a patient's ability to attain best level of independence possible in carrying out routine activities. These include for instance bathing, eating, dressing and grooming. An occupational therapist will provide the patient with adaptive devices including for instance sock pulls for him/her to don socks independently (Howard & Ceci, 2012).  The occupational therapist can assess and then recommend necessary Angela’s home and/or ward environmental modifications to have ramps, handrails among others to ensure the safety and the independence of the patient.

Conclusion

Conclusively, it is clear that nursing plans in the context of chronic and/or complex care must be informed by the main guiding principles. It is even more imperative for healthcare practitioners, patients and family members to understand and grasp these guiding principles. This is because they are the pillars in regard to ensuring patient safety and the quality of care within the hospital facility. In the above discussion there are specific highlights on the major guidelines that need to be used in the development of effective nursing plans within chronic and/or complex care setting.  These include the need for: healthcare and support; teaching and coaching; advocacy and co-ordination and; education, research and evaluation. The presentation explains the different ways towards improving the health outcomes of a patient. Different nursing interventions for included in the nursing plan for a patient who presented with exacerbation of COPD. Even further, the discussion identifies and explains the opportunities which Registered Nurses can use to collaborate with members of the interdisciplinary team while providing care for the patient.

 

References

Chin, E. (2017). The COPD exacerbation experience: A qualitative descriptive study. Applied Nursing Research.

Cramm, J., & Nieboer. (2013). The relationship between self-management abilities, quality of chronic care delivery, and wellbeing among patients with chronic obstructive pulmonary disease in The Netherlands. International Journal Of Chronic Obstructive Pulmonary Disease, 209.

Elder, C. (2017). Health Care Systems Support to Enhance Patient-Centered Care: Lessons from a Primary Care-Based Chronic Pain Management Initiative. The Permanente Journal.

Fromer, L. (2011). Implementing chronic care for COPD: planned visits, care coordination, and patient empowerment for improved outcomes. International Journal Of Chronic Obstructive Pulmonary Disease, 605.

Hodson, M. (2016). The nurse role in addressing malnutrition in COPD patients. Practice Nursing, 27(10), 502-504.

Howard, L., & Ceci, C. (2012). Problematizing health coaching for chronic illness self-management. Nursing Inquiry, 20(3), 223-231.

Ides, K., Vissers, D., De Backer, L., Leemans, G., & De Backer, W. (2011). Airway Clearance in COPD: Need for a Breath of Fresh Air? A Systematic Review. COPD: Journal Of Chronic Obstructive Pulmonary Disease, 8(3), 196-205.

Jan, R. (2013). Pulmonary Embolism as a Cause of Acute Exacerbation of COPD in Patients With Exacerbation of Unknown Etiology. Chest, 144(4), 680A.

Kuharic, J., Sustic, A., Marcun, R., & Lainscak, M. (2015). NT-PROBNP Predicts The Need For Ventilatory Support In The Patients With Acute Exacerbation Of Chronic Obstructive Pulmonary Disease. Intensive Care Medicine Experimental, 3(Suppl 1), A390.

Lau, C., Siracuse, B., & Chamberlain, R. (2017). Readmission After COPD Exacerbation Scale: determining 30-day readmission risk for COPD patients. International Journal Of Chronic Obstructive Pulmonary Disease, Volume 12, 1891-1902.

Parikh, R., Shah, T., & Tandon, R. (2016). COPD exacerbation care bundle improves standard of care, length of stay, and readmission rates. International Journal Of Chronic Obstructive Pulmonary Disease, 577.

Rezapour Nasrabad, R. (2017). Introducing a new nursing care model for patients with chronic conditions. Electronic Physician, 9(2), 3794-3796.

Schiøtz, M., Høst, D., & Frølich, A. (2016). Involving patients with multimorbidity in service planning: perspectives on continuity and care coordination. Journal Of Comorbidity, 6(2), 95-102.

Sciarra, E. (2012). The Importance of Practice Guidelines in Clinical Care. Dimensions Of Critical Care Nursing, 31(2), 84-85. https://dx.doi.org/10.1097/dcc.0b013e3182445f62

Sonola, L., Thiel, V., & Goodwin, N. (2013). Care co-ordination and continuity of care for patients with complex needs: emerging lessons from five models in the UK. International Journal Of Integrated Care, 13(5).

Straughair, C. (2011). Safeguarding vulnerable adults: the role of the registered nurse. Nursing Standard, 25(45), 49-56.

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