Primary Care and the Adult Nursing Patient 'Write a critical account of the health needs of a patient with a long term condition you have met/cared for in the community'

University Degree Subjects allied to Medicine

Primary Care and the Adult Nursing Patient

'Write a critical account of the health needs of a patient with a long term condition you have met/cared for in the community'

Introduction

This essay will provide a critical account of the health requirements of a patient suffering from a chronic medical condition. It will concentrate on the experience of caring for a diabetes sufferer within the community. Due to the nature and longevity of the patient’s condition, a greater standard and longer duration of care was required. The Nursing and Midwifery Council (NMC, 2008) Code of Professional Conduct Guidance on has been maintained throughout this essay and therefore, all names have been altered for the purpose of confidentiality and anonymity. Permission to discuss the case anonymously has been given by the patient and staff involved.

The patient.

Mr Thompson had been suffering from type 2 diabetes for many years. Despite the occasional minor ulcer on his right foot, for a diabetic man of 69 he had generally been in good health. However without his wife, who had passed away three years ago his adult children, whose family commitments meant they were seldom around. His ulcer quickly worsened. The pain became so unbearable that he contacted his surgery and to complain that his foot ulcer made it difficult to walk. It was confirmed that an appointment would be made for Sarah, the district nurse, to visit Mr Thompson at his home.

During her visit Sarah used a Doppler test to examine his foot. According to Bradshaw (1994) concept of need, patients experience different types of needs and it was clear from Mr Thompson’s complaints that a ‘felt need’ was present. Any possibility of a mere exaggerated expressed need was soon eliminated when upon physical examination Sarah found grounds to diagnose the matter as serious. Evidently both normative and comparative needs applied in Mr Thompson’s case-as he was experiencing a higher level of suffering than would normally be expected of a diabetic sufferer. He was therefore referred to a multidisciplinary foot care team.

In order to determine appropriate treatment according to Clinical knowledge Summaries; National Health Service (CKS) (NHS 2009) the team would asked the patient numerous questions. By reviewing Mr Thompson’s medical notes they could identify any history of foot complications and may require repeat, altered treatment methods and medical advice if no foot care advice had been given previously. Mr Thompson stated that whilst he had initially followed all advice given by medical staff he had been very negligent since becoming a widower and this had not been the first time he had required such assistance. In the immediate aftermath of his wife’s death Mr Thompson had shown similar signs of neglect and consequently a Community Matron was assigned to provide help and support. As a Community Matron her role involved caring for the patient in secondary settings and encouraging self sufficiency. Community Matron (NHS 2009) points out that Matrons generally work as part of multi-professional and multi-agency teams with several members involved in caring for one patient. In Mr Thompson’s case the Matron took particular care to include his family in organising a better care plan to control his diabetes and tend to his foot ulcers. She acted as ‘case manager’ a first point of call for general care, providing support and giving advice. She also performed regular examinations on the patient and managed all comprehensive medical history notes. Such extensive planning, partnerships, follow-up visits, assessing and evaluating, were essential to meet his ever-changing health and social care needs. But in such situations the job of a Community Nurse is far from easy. Their schedules can be erratic visiting patients monthly or as frequently as several times a day.

Recent government policies aim to improve the quality of patient care, reduce the number of hospital patients and deliver more health care to patients at home. But this coupled with the aging UK population and increased diabetic survivor rates means the demand for (out-patient) care is increasing. On one hand such statistics positively indicate success in medical advancements and a healthier population; however the link between old age and diabetes may also explain the increased number of sufferers. The overall effects are that hospital staff are increasingly struggling to meet demands. Shift work may rise and even fewer Matrons will work independently on a case-by-case basis, thus resulting in a breakdown of strong patient-nurse relationships. Instead continuity of care may operate primarily through partnerships, shared nursing roles and the involvement of social services, voluntary agencies and NHS organisations such expert Patient Programmes Community Matron (NHS 2009). However with a number of cases involving staff negligence and abuse of elderly patients proper training and monitoring of staff would be crucial but may also prove time consuming and costly. (Leeds general hospital 2007)

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Due to the interpersonal nature of their duty, District nurses play a crucial role in the primary care those suffering from long term illnesses. Their home visits and interaction with family members, provides emotional support by developing close trusting relationships, and quickly identify health problems. With Mr Thompson’s growing dependency on carers and unsuitable home conditions, Sarah decided it best to admit him into a residential care home. By consulting his family and obtaining his permission before finding a suitable home she executed a good care giving strategy. The Darzi’s report Department of Health (DoH 2008) view that patients should be given a choice in care plans, and also with his legal right to privacy. It is likely that the nurse-patient bond heavily influenced the cooperative decision-making process and eased the transition from full independency to a primary like setting. At the same time District Nurses must act as teachers and counsellors, helping patients regain independence by showing patients or carers how to confidently perform care-giving duties in the absence of the nurse. Therefore play an indirect but crucial role in keeping hospital admissions and readmissions to a minimum.

The physiological effects of diabetes can be extremely burdensome and due to the likelihood of glucose damaging the nerves, they are prone to infected extremities leading to problems like diabetic foot. To prevent such issues (CKS) (NHS 2009) point out that sufferers must take particular care to keep fingernails and toenails short and clean and wear specialist shoes. Feet should be checked regularly for cuts, blisters or grazes which might otherwise go unnoticed if there is nerve damage and loss of sensation. The multidisciplinary team should be alerted should minor injuries worsen or do not start to heal within a few days.

According to (CKS) (NHS 2009) the risk of developing type 2 diabetes increases with age, possibly because as people age they become less active, gain weight- and this affects their mobility and weakening their circulatory system. However this viewpoint is fairly weak as whilst white people over the age of 40 are prone to developing the illness, ethnic minority groups are affected from age 25 years upwards. This distinction suggests that diabetes may relate to dietary choices. Another possible explanation for the development of type 2 diabetes is a genetic link, where people are more likely to develop diabetes when a close relative already has it. There is also an increased risk of developing type 2diabetes if a person has either impaired fasting glycaemia (IFG), or impaired glucose tolerance (IGT). These conditions are sometimes also known as pre-diabetes, and mean that blood glucose level is higher than usual, but not high enough to cause diabetes. IFG and IGT can both progress into type 2 diabetes if preventative measures are not taken.

Even after diagnosis (DoH 2008) suggest that measures can be taken to improve the lives of diabetics. Although diabetes cannot be instantly cured, it can be controlled using medication and other therapies. Foot problems caused by diabetes mean more patients spend more time in hospital and thus hospital resources are used on treatment or surgery, which is often very costly. But research such as that conducted by the NICE guidance recommends, (alongside a regular review of patients’ feet), care from a multi-disciplinary foot care team National Service Framework (NSF 2005). Such teams operate using a good level of interaction and communication. They aim to identify risk factors, eliminating or prolonging the development of ulceration and can significantly reduce the incidence of complications and amputation (Armstrong et al 1998, Edmonds et al 2004). Additionally the preliminary diabetic foot assessment is the keystone to any preventative management strategy. Once possible causes of ulcers are identified measures can be taken to counter such risks. However such assessments are based solely on probabilities and the key causative factors are neuropathy, peripheral arterial disease and elevated foot pressures caused by deformity, callus and/or footwear (Edmonds et al 1999, National Institute for Clinical Excellence (NICE) 2004).

Expert Patient Programmes (DOH 2007) have also proved beneficial and involves lay members who nurse patients. Reports suggest they have been considerably successful at regaining patients’ independence. Often, particularly with older diabetics, conditions greatly limit their ability to perform mundane tasks, hindering their quality of life (DoH, 2007). However negligence, as in the case for Mr Thompson meant that he was eventually forced to revert back to the primary care of the hospital, where he underwent an extensive array of medical procedures. The surgeon drained and debride his infected feet, grafted skin over large defects, performed vascular bypasses and amputated unsalvageable limbs. Interventional radiologist x rayed Mr Thompson’s foot interpreted the X-rays and performs angiography and angioplasty. Clearly extreme measures were also taken by staff to promote self care by ensuring he was well educated about prevention. According to Foster A, Edmonds M (2001) The Orthotist would provide suitable footwear and foot care advice, the nurse cleansed and dressed his wounds and further advised on wound care, the podiatrist performed neurological and vascular assessments and acted as the patient’s advocate. Although great measures were being taken to prevent Mr Thompson’s condition from worsening such a lengthy and traumatic ordeal could have been avoided had he been properly monitored and reviewed whilst living independently. His hospitalisation had defeated the key government objective. However with increasing medical knowledge it is becoming easier to take preventative measures, such as targeting high risk groups.

Even with medical advancements and increased life expectancy, Diabetes remains the world’s 5th leading cause of death and the number of sufferers is said to be increasing. The health profile of Medway shows no significant difference compare to England average. It is probable that improved preventative measures should be developed. For instance whilst the overall population of Medway and Kent is predominately white, some parts of the county (particularly in the north) are more ethnically diverse. Therefore hospitals should apply policies which reflect these ethnic variations across the county. Understanding such differences enables healthcare and health promotion messages to be targeted in appropriate ways (Kent and Medway public health observatory NHS 2008). The (DoH) (2008) points out that the health profile of England shows some recent improvements in a number of critical areas for example declining mortality rates in targeted killers such as cancer and circulatory diseases. However similar successes cannot be attributed to research on diabetes, and the rates continue to rise. Although surveys can provide a useful guide, for instance a survey by the department of health drew a connection between a high prevalence of diabetes and population with greater obesity levels.

In April the Secretary of State for Health launched Putting Prevention First, which set out plans for the NHS to deliver a national programme of vascular checks for everybody aged 40–74. This ambitious programme will, for the first time, carry out a systematic, integrated risk assessment of those members of the population who are most at risk and who, according to the evidence, have the biggest opportunity to benefit. Five Years on – Delivering the Diabetes (NSF) (2008). When the National Service Framework standards were first published in 2001, only around 1.3 million people were diagnosed with diabetes, and it was thought that around a million had diabetes without knowing it. Since then, the Quality and Outcomes Framework (QOF) has rewarded GP practices for the identification and treatment of people with diabetes in their area and consequently there are now almost 2 million diabetic adults recorded on practice registers. This means that around 600,000 people have been diagnosed in the last five years – equivalent to 2,000 a week – and are now benefiting from the support they need to manage their diabetes (NICE 2009).

Care planning is a key part of managing long-term conditions, and its importance has been stated in a number of major policy documents. The final report of Lord Darzi’s, NHS Next Stage Review, High Quality Care for All, stresses that, over the next two years, everyone with a long-term condition should be offered a personalised care plan. In February 2008 the National Diabetes Support Team (2008) produced its guide to implementing care planning in diabetes Partners in Care and is also working with Diabetes UK and other key partners to determine ways to support the NHS in embedding the principles of care planning into the delivery of diabetes services (NSF 2008). It has been reported that Primary care is getting better at managing diabetes and one of the outstanding achievements of the Quality and Outcomes Framework is the rising numbers of diabetics receiving essential tests and measurements (for example, blood pressure and cholesterol). And better still the results of those tests have also indicated health improvements, however it is important to note, that the 2005/6 National Diabetes Audit found that not everyone is receiving every care process that they need indicating that we still have some way to go. It’s also vital that the person with diabetes is provided with as much information as possible prior to their appointment, to help them use their time with the healthcare professional as well as possible. This was a theme of the final report of the NHS Next Stage Review, which acknowledged that too few people have access to information about their own care (NSF 2008).

Services

There are many innovative strategies that authorities can adapt to meet the needs of different sections of the community. In Kent the community diabetes nursing team give continued care and advance throughout all stages of diabetic suffering. The team educate those newly diagnosed with type 2 diabetes in clinic and group settings across Medway and Swale and also run group sessions for those who need to start insulin, usually via the telephone triage system, based at Parkwood Health Centre. Home visits for the housebound are undertaken, as are visits to patients in the community and mental health wards, residential and nursing homes and Prisons. The Community Diabetes Nursing team undertake the following a wide range of duties providing in-depth advisory and educational support.

National Frame work

This National Service Framework (NSF 2005) for Long-term Conditions is a key tool for delivering the government’s strategy to support people with long-term conditions aiming to build on proposed changes in NHS management and commissioning to bring about a structured and systematic approach to delivering treatment and care for people with long-term conditions to improve health outcomes for people with long-term conditions by offering a personalised care plan for vulnerable people most at risk; to reduce emergency bed days by 5% by 2008 through improved care in primary care and community settings for people with long-term conditions; to improve access to services, ensuring that by 2008 no one waits more than 18 weeks from GP referral to hospital treatment, including all diagnostic procedures and tests. The (NSF 2005) fully supports the concept of choice set out in Building on the Best: Choice, responsiveness and equity in the NHS. This aims to ensure that all people have a choice of when, where and how they are treated from onset of illness until the end of life.

Conclusion:

This essay had shown a critical account of the health requirements of a patient suffering from a chronic medical condition highlighting the importance and the need of caring for a diabetes sufferer within the community. Mr Thompson’s case had shown that as diabetic suffer and the problems he had with his foot. The appropriate treatment was essential in order to deal with his problem the involvement of a multidisciplinary team help to provide the necessary treatment to help Mr Thompson. Community Matron and the district nurse played an important role by acting on behalf of the patient who is suffering from a long term illnesses ensuring that the patient received the appropriate care they need formulating a care plan to help control his diabetes and tend to his foot ulcers. The risk of developing type 2 diabetes is know to increase with age, and may be due to people at an older age becoming less active, gaining weight tends to affects their mobility and weakening their circulatory system. The Department of Health recommend that measures can be taken to improve the lives of diabetics. Although diabetes currently cannot be immediately cured, by using medication and other therapies it can be controlled. However Foot problems that are caused by diabetes signify more patients are more likely to spend more time in hospital using up hospital resources which is can be very costly. NICE guidance recommends that regular review of patients’ feet should be undertaken by the care from a multi-disciplinary foot care team whose aim are to identify risk factors, (Armstrong et al 1998, Edmonds et al 2004) points out the importance of eliminating or prolonging the development of ulceration and can significantly reduce the incidence of complications and amputation. The government’s aims are to support people with long-term conditions by delivering recommend changes that will help people with long-term conditions. There are services within the community that provide support and education for diabetes suffers In Kent the community diabetes nursing team play major role in this time service.

Reference:

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Armstrong,G. Lavery, A. Harkless, B. (1998) Who is at risk for diabetic foot ulceration? Clinics in Podiatric Medicine and Surgery. 15, 1, 11-19.

Bradshaw, J.R. (1994) 'The conceptualisation and measurement of need: a social policy perspective', pp 45-57 in Popay, J. and Williams, G. (eds), Researching the People's Health, Routledge: London

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Foster, A. Edmonds, M. (2001) An overview of foot disease in patients with diabetes. Nursing Standard. 16, 12, 45-52.

(Leeds general hospital 2007) ??????

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Primary Care and the Adult Nursing Patient 'Write a critical account of the health needs of a patient with a long term condition you have met/cared for in the community'

This is a preview of the whole essay

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