Understanding Long Term Health Conditions

Introduction

The long-term health condition (LTC) is referred to health problem which requires continuous management and intervention over the years to help the patient lead a normal life without facing challenges due to presence of the disease (Velardo et al. 2017). The proper cure for the long-term condition is still not available. In England, there are nearly 15 million people are found to be suffering from the long-term condition which is projected to rise to 18 million by 2025 (Gov, 2015; Assets UK, 2012). According to reports, 14% of people who are under the age of 40 years and 58% of people over 60 years are seen to be suffering from long-term condition. In addition, nearly 25% of the people who are above the age of 60 years are found to suffering from multiple long-term conditions (UK Parliament, 2014).

One of the long-term conditions which have affected many individuals in the UK is Chronic Obstructive Pulmonary Diseases (COPD). As per the last reports published by the Department of Health in the UK nearly 1.2 million people in the country are suffering from COPD (NICE, 2018). This indicates that 2% of the entire population within the UK are suffering from the illness and out of them nearly 4.5% of the individuals are above the age of 40 years (British Lung Federation, 2017). In 2015, it is reported that nearly 3 million individuals who are suffering from COPD have died (World Health Organisation, 2016).

In between 2008 and 2012 it is found that the prevalence of COPD among the UK individuals has increased by 9% (British Lung Federation, 2017). The figures indicate that effective interventions are to be required to lower the incidence of COPD among the UK population. Thus, a case study of a patient suffering from COPD is to be mentioned in this assignment to understand the symptoms and causes related to the illness and discussion is to be made regarding its pathophysiology. The physical, social and psychological challenges related to COPD with the case study are to be analysed. Further, nursing care, integrated care, health promotion and patient empowerment-related with the COPD patient is to be discussed about the case study to understand the interventions to be made to cope with the illness.

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Confidentiality Statement

The NMC Code under the “Prioritise People” mentions that people’s right to confidentiality and privacy is to be respected (NMC, 2015). Thus, to maintain the confidentiality of the patient to comply with the NMC Codes of Contact pseudonym of the patient’s name is to be used so that the identity of the individual remains protected. Moreover, the name and location of the patient to be mentioned in the case study are to be anonymised to protect the individual from any harm or abuse which may be caused by revealing their location and age.

Case Study

The case study to be presented is of the patient named Mrs R who is aged 72 years and is currently living alone. Mrs R’s husband who was aged 75 years has expired six months ago due to an accident and her single daughter is currently outside the country with her husband and one six-month-old child. The case history of Mrs R informs that she has been a chronic smoker and for the past 30 years is smoking 10 cigarettes a day. She was admitted to the hospital eight years ago due to difficulty in breathing along with coughing, increased mucus production and wheezing. The healthcare practitioners based on her health analysis and symptoms conducted a Spirometry Test to detect if she had COPD. According to National Institute of Health and Excellence (NICE), the ratio of FEV1 (Forced Expiratory Volume1)/FEV6 (Forced Expiratory Volume6) (FVC) for normal individuals is equal to or more than 70% (NICE, 2015). However, the spirometry test for Mrs R revealed that the ration of FEV1/FEV6 (FVC) was less than 49% which indicates that she is suffering from COPD. Mrs R was initially cared for one month in the hospital and later was sent home where she was put under the care of her husband and a service provider who would weekly visit them to ensure the care plan mentioned for Mrs R is properly followed. Mrs R under the care of her husband was found to show controlled health even after having COPD. After the death of her husband, she was provided a carer who would help her in executing everyday activities and manage household activities. However, for the past four months, it is found that a sudden relapse in the symptoms related to COPD is seen which has made her get currently admitted to the nearby hospital. In addition, she was found to be untidy with reduced body weight than normal and have developed the habit of smoking again.

Pathophysiology of COPD

The ciliated epithelium is present in the inner lining extending from the nasal cavity to the bronchi. The bronchi are bifurcated which enters the left and right lungs where they are branched into bronchioles. The bronchioles contain tinny air-sac known as alveoli that are encompassed by blood capillaries playing the role in relaying oxygen and carbon-dioxide inside and outside the blood (Radovanovic et al. 2018). In case of patients with COPD like Mrs R who are active smokers, it is seen that the ciliated pseudostratified columnar epithelium that is present in the inner lining of the bronchial tubes are damaged which leads to produce increased amount of mucus, in turn, blocking the lungs (Mitchell, 2015). This makes patients with COPD experience shortness of breath and wheezing along with chest tightness as presence of mucus due to destroyed air sacs in the lungs interferes with the outward flow of air.

The accumulation of increased amount of mucus in COPD patients is seen to be caused through the dysregulation of EGFR (Epidermal Growth Factor Receptor) pathway. This is evident as the presence of Human Epidermal Growth Factor (HER) 1 and 3 in the EGFR pathway which controls mucus secretion by goblet cells in the body are seen to be active at an increased level to produce excess mucus (Stolarczyk et al. 2016). The pro-inflammatory TNF-α factor which also promotes pro-inflammatory TNF-α secretion as a result of inflamed airways is found to signal increased HER 1 secretion. The changes create an autocrine effect that results in increased differentiation of goblet cell resulting in increased mucus secretion in COPD patients (Bozinovski et al. 2016).

Physical, Social and Psychological Challenges related to COPD

The presence of COPD as the long-term condition often leads the patient as well as their carer experience physical, social and psychological challenges. As mentioned by Wheaton et al. (2015), patients suffering from COPD often experience shortness of breath while executing physical activities. It makes patients suffering from COPD experience physical challenge of being unable to execute household work required for everyday purpose. This is because household works are regarded to be physically demanding by COPD patients. Therefore, executing them would lead the individuals to experience breathing problem making them gasp for breath (Nyberg et al. 2016). In the case of Mrs R, it is seen that she experiences limitation to execute household activities as result of breathlessness and thus a caregiver is provided to help her in performing the activities. As argued by Kentson et al. (2016), the presence of COPD leads individual to experience fatigue because of the increased effort they required to put in to breath. This creates physical challenge for the individuals to feel weak and unable to perform everyday activities. In case of Mrs R, it is seen that she is experiencing similar condition due to which she is unable to maintain proper cleanliness and have proper amount of food to maintain her weight.

Social Challenges

The presence of COPD creates challenges for the individuals to maintain proper social network and exposure as it makes them experience breathlessness. This is evident as shortness of breath makes individuals with COPD unable to talk properly and travel long distances through walking. Thus, it makes tem remained confined at home leading them to be unable to maintain proper contact with friends and relatives. Moreover, it is mentioned that physical limitation created by COPD makes patients unable to attend social gathering (Kouijzer et al. 2018). Thus, it limits their social boundaries making them feel isolated from the society as they cannot meet their friends like before the illness at parties and gatherings.

Psychological Challenges

In the study by Kouijzer et al. (2018), social limitation of the patients with COPD makes them depressed. This is because they are unable to socialise making them feel unhappy as they are unable to share their emotions with others as seen in case if Mrs R where she is found to remain at home most of the time. Thus, the depressed feeling of being confined to home may have led Mrs R to remain addicted to smoking as it is used as her way of alleviating her stress. As argued by Tselebis et al. (2016), the presence of COPD as long-term condition makes patients develop anxiety. This is because COPD makes individuals suffer increased pain and tightness of chest making them feels ill. This is seen in case of Mrs R and it has result her become anxious that she may die at any moment. As asserted by Sigurgeirsdottir et al. (2019), people with COPD as the long-term condition often develop depression because they are unable to execute activities without help which they used to do on their own. In case of Mrs R, it is seen that she has developed depression as well as anxiety which is evident as she often expresses the feeling that she is now going to die as she cannot breathe properly.

Carer challenges

The presence of COPD patients in the family creates challenges for the family carer. This is because they are dependent for care on the individuals for helping them in everyday activities which needed physical strength and energy (Cruz et al. 2017). In case of Mrs R, it was seen that while her husband was alive he had the sole responsibility of supporting Mrs R in everyday activities such as bathing, cooking food, maintaining hygiene, cleaning and others. In the absence of her husband, there is currently no family carer for Mrs R on whom she can be dependent. Mrs R’s daughter is seen to be living overseas and presently have delivered a child. In this condition, the burden of care has fallen on her daughter as there is no more family member present. Thus, her daughter has allocated a caregiver in her absence to offer support to Mrs R. As mentioned by Farquhar (2018), carer of patients with COPD often experiences fatigue and physical exhaustion. This is because they have to experience burden of care of the patients as the individual becomes unable to perform activities out of breathlessness. In case of Mrs R, it can be considered that the carer due to physical exhaustion may be unable to offer her proper care that has resulted her to experience relapse of her COPD symptoms along with smoking habit making her get admitted to the hospital. As argued by Rosa et al. (2017), carer of COPD patients experiences emotional stress and anxiety. This is because they have limited time to relax and often experience the unpredictability of the disease trajectory.

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Nursing care

The NICE guidelines mention that effective nursing actions are required to be performed with the key purpose of supporting improved quality health goals for the patients (NICE, 2015). In relation to the NICE guidelines, the nurse caring for Mrs R made her attend group counselling to quit smoking. As asserted by Hagens et al. (2017), in group counselling for smoking the individual who is trying to quit smoking can meet different experienced speakers and counsellor who provides advice on the way to quit smoking and manage relapses. As commented by Stegberg et al. (2018), individuals suffering from COPD require to cease smoking as the harmful particles present in the tobacco smoke further damages the inner lining of the lungs as well as air sacs. This informs that continuing to smoke who more extensively affect the relapse of COPD as the airways would be intensely damaged. Thus, group counselling for Mrs R is especially required because it is mentioned that she has been addicted to smoking that is deteriorating her health as well as flaring up COPD. The NICE guidelines mention that proper medication is to be provided to individuals with COPD who are involved in smoking to avoid further damage of the lungs and develop better control of health condition of the individuals (NICE, 2018). Since Mrs R was involved in smoking, thus according to NICE guidelines varenicline or bupropion as medication is provided to her to help her quit smoking to control her health.

In order to care for Mrs R, the nursing action involved providing bronchodilators to her. As mentioned by Price et al. (2017), bronchodilators are referred the substance which is used for dilating the bronchioles and bronchi of the individuals. This is because it would reduce resistance in the airways, in turn, increasing airflow through the lungs making the individual with COPD experiencing better breathing efficiency by avoiding wheezing and chest tightness. Since Mrs R was reported to mention wheezing and chest tightness, thus long-acting bronchodilator formoterol was provided to her through inhaler as a quick-relief medication. The long-acting bronchodilators include formoterol, salmeterol, arformoterol and others (Halpin et al. 2016). In addition, the nurses to reduce airway inflammation as seen from the reports of Mrs R who is suffering from COPD provided phosphodiesterase-4 inhibitors to the individual. As asserted by Grundy et al. (2016), phosphodiesterase-4 inhibitors are the medication provided for reduction of airway inflammation and relaxation of airways. This impacts individuals with COPD to breathe effectively. In order to Mrs R breathe properly, the phosphodiesterase-4 inhibitors are provided so that through relaxation of the airways improved breathing can be established.

Integrated Care

Integrated care is referred to the principle of care delivery which has the key aim to improve the health of the patients through improved coordinated care. In order to successfully provide effective integrated care, various professionals and health practitioners from different sectors are to work together by determining the needs of the service user (Flanagan et al. 2017). The integrated care for Mrs R includes multi-disciplinary team who are involved to offer her effective care to manage her condition related to COPD. The House of Care Model is referred to the framework developed by the NHS England through which they planned offering coordinated care to the patients suffering from long-term condition. This is to be done by making clinical professionals work together to share and support well-being and improved health condition of the patients (NHS, 2019).

The House Care Model explains four key components that are to be followed to provide integrated care to the service users out of which engagement as well as informing service users and carers regarding care are to be done as one of the components of care (NHS, 2019). This is to be done so that the patients are able to self-manage their health requirements and have information regarding when and where to approach for fulfilling their care needs (NHS, 2019). It indicates that Mrs R is to be informed by the nurses and health professionals in a collaborative way regarding the way she can manage her own health condition. Moreover, she is to be informed as per the aspect of the model when and where to ask for help if she is unable to manage her own health or experiencing issues with care delivery. For instance, she is to be informed that when she is unable to manage her hygiene and experiences non-cooperative as well as hindered care from the carer she is to approach the healthcare council and healthcare professionals to report the experience. This is because it would help her to access support from the council and may be her present carer is changed with another who would deliver her better and satisfactory care to ensure her better physical health.

The other component of House of Care Model is to develop structured organisational and clinical process to ensure evidence-based care that is framed considering the needs of patients and carers and is being co-designed with the help of service users where possible (NHS, 2019). This aspect of the model informs that to provide integrated care to Mrs R she is to be included in deciding the way and types of care are to be provided to her. In addition, Mrs R’s needs after her husband’s death are to be analysed to determine what extra needs may rise which are to be fulfilled for providing her satisfactory care. For instance, after Mrs R husband's death, she may be feeling lonely and depressed due to which she may have started using tobacco to get relive from sorrow. Thus, the carers around Mrs R is to provide her counselling to help her get over the grief and is to be referred to respiratory nurse specialist who would inform her regarding the way she can control her replaces COPD symptoms to ensure normal breathing. (Refer to Appendix 1)

The other component of House of Care Model is partnership working of healthcare professionals where different professionals from diverse fields are to work together in supporting and providing collaborated care to service users for their well-being (NHS, 2019). This aspect of the model informs that multi-disciplinary team (MDT) where respiratory nurse specialist, psychiatrist, clinical health professional, dieticians and others are to be present to listen to the needs of Mrs R. This is to be done so that through collaborative care from the MDT Mrs R’s emotional health as well as physical complication raised due to relapse of COPD is to be effectively controlled. The commissioning of care is another component of House of Care Model according to which improvement in the system of care delivery process is to be made based on the outcome of each cycle of care to inform the next one for the patient (NHS, 2019). Thus, according to this component, the health professionals are to analyse and examine the experiences of care satisfaction of Mrs R regarding the previous care cycle to develop the next cycle of care where her relapsed symptoms of COPD and other physical health issues is to be maintained more effectively to ensure better health condition. The benefit of using the House of Care Model is that it informs the way multi-disciplinary action in integrated care can be established to offer better care support. However, the limitation of using the model is that challenges to be faced during multi-disciplinary coordination and the way to resolve it for the success of care delivery is not mentioned (NHS, 2019). Thus, using the model is unable to provide information about the solving issues with MDT.

The Five Year Forward View is developed with the key aim to establish improved health of patients by offering them quality care and making cost-control. This is to be done by allowing single group of professionals take the role of delivering primary and community care along with mental and hospital services for the patients to improve their well-being and care after discharge from the hospital (NHS, 2014). The primary and specialist service as mentioned in the Five Year Forward View is to be provided by the group in case of integrated care for Mrs R by including services from respiratory specialist nurse along with medication management and improved everyday care support through primary care. This is because it would help the patient to avail special care required to treat her COPD and get assistance in executing her primary everyday activities with ease. The mental and physical health services are to be provided by the team to Mrs R according to the Five Year Forward View integration by offering her clinical assistance for COPD and providing her mental counselling in improving her emotional health which may be deteriorated with the loss of her husband and long-term suffering from COPD to ensure effective well-being. In order to offer these services, the team require including multi-disciplinary care professionals such as dieticians, respiratory nurses and others. The benefit of using Five Year Forward View to arrange integrated care is that it helps to ensure improved quality care is provided to patients by accessing coordination from wide number of professionals from different field (NHS, 2014)

Health Promotion and Patient Empowerment

In order to promote health of Mrs R, the nurses required to follow 6 C’s of nursing principle. The 6 C’s of nursing are care, compassion, competence, communication, courage and commitment (Bradshaw, 2016, NHS, 2013). The care in 6 C’s means nurses are required to deliver high-quality individualised care to serve users based on understanding patient’s needs and demands (Baillie, 2017). This indicates the nurse for health promotion of Mrs R is required to understand her specific needs and demands according which high-quality services such smoking cessation program, lowering her depression, providing her better carer to support and others are to be developed for delivering it to her. As asserted by Baillie (2017), compassion in 6 C’s means nurses are to show empathy and kindness towards the service users. This is because it makes the service users feel dignified and respected. Thus, in case of Mrs R, the nurses are to show empathy and compassion through their services for creating a successful health promotion for her as she is already been depressed with her health and the recent loss of her husband who was her main carer. As argued by Farver-Vestergaard et al. (2018), failure to show compassion creates hindered health promotion for patients by nurses. This is because uncompassionate services make patients feel lack of value and dignity making them avoids accessing services from the nurses.

Competence indicates the proper knowledge and skill to execute care activity by nurses (Bastos et al. 2019). However, in case of Mrs R, it is seen that the carer offering her support lack competence in providing services to COPD patients due to which relapse in her health condition and sudden admission to the hospital is been triggered. Therefore, the nurses for health promotion of Mrs R are to allocate a properly skilled carer who would be able to control her care to ensure she avoids smoking and shows reduction in symptoms of COPD to lead a better life. The communication to promote health among patients is essential so that effective shared-decision can be taken (El-Soussi et al. 2015). The NMC Code also mentions under “Practice effectively” to clearly communicate with service users to make shared-decision regarding their care as well as inform them in detail regarding the care support to be provided (NMC, 2015). Thus, shared-decision through communication for Mrs R is to be made by nurses as it would make her feel empowered of being able to participate in deciding her own care. Moreover, effective communication helps nurses understand the patient's needs and make them informed the way care being offered is going to help them resolved their long-term health condition (NMC, 2015).

The courage indicates that nurses need to decide the best for the patients and commitment indicates that nurses required to have a proper vision about the way health promotion of the patient is to be executed (Baillie, 2017). In addition, NMC code under “Promote professionalism and trust” indicates that nurses are to be committed to deliver standard practices to ensure better health of the patients (NMC, 2015). Thus, in respect to Mrs R, it is seen that she may be avoiding quitting smoking but the nurses require having courage and commitment to make her cease smoking irrespective of her wish to ensure her health condition is promoted.

The patient empowerment for Mrs R is to be developed by following the Transtheoretical model (TTM). The TTM includes six stages which are pre-contemplation, contemplation, preparation, action, maintenance and termination. In the pre-contemplation stage, the patients are often seen underestimating the pros and cons of the impact of their current activities on their health (Ma et al. 2016). Mrs R is seen to be in the precontemplation stage as she is not considering the negative impact her smoking habit has on her health. Thus, the nurses in this stage need to offer care and make communication as a part of 6 C’s of nursing regarding negative effects of smoking to empower Mrs R to cease smoking. It indicates that they are to make her include in group counselling programs as mentioned in the nursing care. This is required so that she can be made to understand the negative effects smoking has on her health and COPD intending her to quit smoking. In contemplation stage, the patients are intended to initiate the health behaviour (Williams et al. 2017). It indicates Mrs R when reaches this stage would show intention to quit smoking and to ensure she remains empowered to execute it the nurses are to be competent to support her as mentioned in 6 C’s of nursing. This is because without competency the nurses would fail to support Mrs R’s intention to quit smoking which may make her change path to avoid cessation out of lack of skilled support and direction.

In preparation stage, the patients show determination to make the change in their behaviour (Disler et al. 2016). Thus, in this stage, to make Mrs R remain determined and empowered to execute the behaviour change nurses are to properly communicate as per 6 C’s of nursing of the steps to be followed by her to achieve the action. In the action stage, the patients are seen to execute the changed behaviour and in the maintenance stage, the individuals try to sustain their behaviour (Disler et al. 2016). In these stages, to make Mrs R remain empowered to achieve cessation of smoking the nurses are to provide her information about the way she can be psychologically strong to execute the action. On reaching the termination stage, Mrs R would be seen to have effectively empowered to achieve cessation of smoking, in turn, ensure her improved health while living with COPD.

Conclusion

The above discussion informs that Mrs R is suffering from COPD for the past 5 years and recently has shown in relapse of symptoms which was previously controlled. The pathophysiology informs that COPD is raised due to intensive smoking which results individuals to feel breathlessness, wheezing and chest tightness as symptoms. The nursing care developed for Mrs R includes offering her group counselling, medication for smoking cessation, medication for COPD management and others. The integrated care for Mrs R includes multi-disciplinary team such as respiratory specialist nurse and dietician to offer her proper care. In order to promote health of Mrs R and to empower her, the 6 C’s of nursing and transtheoretical model are used.

Recommendations

In order to offer effective care to Mrs R, it is recommended that nurses are to arrange psychological counselling of Mrs R so that her depression and stress regarding her health due to COPD can be resolved. This is required so that she develops better emotional strength to cope with the disease and respond in a better way to the treatment. Moreover, it is recommended that skilled carer is to be provided to Mrs R for support her in daily activities and household chores so that her health could be improved.

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