DEVELOPING ADULT NURSING CARE

With this essay, the names and setting will not be disclosed in order to protect confidentiality. The content within this essay is generalised across a patient group and does not relate to any specific patient, staff member or trust (NMC, 2018).                                                                                                                                                              The aim of this essay is to identify a patient group with a specific health need relating to a long-term condition they are living with. It will prioritise this health need with a specific focus on a holistic approach to nursing assessment, when assessing patients with Chronic Obstructive Pulmonary Disease, known as COPD. It will locate the point of the trajectory of the disease, as well as the care environment the assessment takes place with, and why these are important in relation to the relevance of the chosen assessment.                                               COPD is one of the respiratory diseases which requires palliation of symptoms, is known to have four stages within its disease trajectory beginning with mild, moderate and progressing to moderately severe (Currie, 2017). The term ‘health trajectory’ describes changes in health over period of time, defending the stage a patient is at in their health trajectory allows for effective intervention and care planning ( Seamark et al, 2007).The patient group for purpose of that assignment are within the   severe stage of their illness with long term limitation of function and well-being with intermittent serious episodes of COPD progression .Disease trajectory during the third stage of COPD patients experience exacerbation which can have a big impact on life quality (limitation) and often requiring hospital admission (Curie,2017). A study by Lunney et al (2002) introduce End of Life as its own phase, divided int four distinct trajectories varying in length and rate of decline in functionality.                               By Lunney et al (2002) trajectory has a four different End of Life Stages: terminal, frailty, sudden death and organ failure.  The essay will introduce and describe the assessment tools used for individual health care needs and explore the need for holistic assessment based on the activities of daily living, using the Roper, Tierney, Logan model ‘Activities of Daily Living’ (ALD’s). ADL’s are what people take advantage of in everyday life, for example, bathing, dressing, work; (Roper et al, 2000). Twelve activities of daily living are used to measure a patient’s ability, they are: “maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying”. Performing ADL’s can help to gather as much information as possible, for example, does the patient live alone, is the patient is able to carry out basic tasks (washing, dressing, etc.). It helps to identify areas of risk, as well as highlight person own individual health, needs to support a patient’s journey. “Understanding the breadth of patients’ support needs is important for the delivery of person-cantered care, particularly in progressive long-term conditions such as chronic obstructive pulmonary disease (COPD). Existing reviews identify important aspects of managing life with COPD with which patients may need support”. COPD may continue to get worse despite treatment, eventually having a significant impact on their quality of life and leading to life limiting prognosis. Although COPD is a bracket name given to multiple lung conditions such as emphysema and chronic bronchitis the two conditions are very similar and often present with similar symptoms. (Ashelford et al, 2016). COPD has a wide spread effect on the body effecting weight loss, exercise intolerance and peripheral oedema, It is estimated around three million people in the United Kingdom (UK) are living with COPD, but the National Institute for health and care excellence reports only 900,000 of those have officially been diagnosed (NICE, 2010).

The main focus within this essay will be on the need for nutrition for those with the long term condition of COPD as many patient with COPD are underweight and malnourished (Currie, 2017).

The essay will introduce and describe the assessment tools used for individual need, and explore the use of that assessment as an integral part of an overlooking, holistic assessment of the needs of the chosen patient group, developed via the creation of an effective therapeutic nurse-patient relationship, as well as involvement of the families, carers, as well as multi-disciplinary team. This assignment will highlight the key clinical manifestations of an acute exacerbation in a COPD patient and will discuss the strategies for care management. Understanding a patient’s perception of their illness is an important first step to providing comprehensive, multifaceted care for patients with long term conditions.  Being able to self-manage, not least because COPD is specific to the individual and can change on daily base, because of that educating a patient is key. Each long term condition comes with a set of challenges. This essay will focus on the group of the patients in a hospital environment which suffer from the chronic obstructive pulmonary disease (COPD) with a priority need for nutrition on the body and patient’s quality of life. Chronic obstructive pulmonary disease is a progressive lung disease characterised by airflow destruction and destruction of the lung parenchyma (GOLD, 2019). The Global Initiative for Chronic Obstructive Lung Disease (2019) states that COPD is a preventable and treatable disease. National Institute of Clinical Excellence (NICE, 2011) highlight “COPD is the fourth highest mortality rate being one of the costliest conditions treated within the NHS, with a total annual cost of over 800 million in direct healthcare costs. COPD is often characterised by persistent respiratory symptoms that effect the airflow limitations caused from long term chronic inflammation that damages the respiratory system by effecting tiny air sacs within your lungs, causing the peripheral airways to become narrower and thicker, which then results in restricted airflow, making it harder for COPD suffers to breathe and empty their lungs causing them to suffer breathing difficulties and breathlessness, often involving a long term chronic cough and increased mucus production”                                                                            According to NICE, “around three million people in the UK are affected, two million of whom are undiagnosed. It causes 115,000 admissions to hospital every year. Most people find out they have COPD in their fifties or older, and it’s much more common in people who smoke. Breathing problems tend to get gradually worse over time, but there are many different medicines and therapies that can help people keep these under control for longer” (NICE, 2016). Symptoms include increased breathless, especially when people are active, a persistent cough with phlegm, frequent chest infections and wheezing. Breathing problems tend to get gradually worse over time, limiting everyday activities, although treatment can help to keep the condition under control. The patient may experience exacerbations when symptoms become more severe (NICE, 2018). Over the last few decades, the study of COPD has become one of the most rapidly developing fields in medicine (Lee, 2017).  Exacerbation can often be caused by viruses and bacterial infection, patient with frequent exacerbation have an increased risk of decline in their lung function what and consequently impairs quality of their life, as well as putting a pressure on family, carers (Lung Institute,2017). Furthermore, evidences show that COPD gradually gets worse over time, however for many people treatment can be offered for better management of COPD, which improves quality of life and decrease limitation in their daily activities of life (British Lung Foundation, 2019). COPD has often been misdiagnosed as asthma due to similar symptoms, presentation, lack of knowledge, training and understanding around the disease its symptoms and causes study shows those who are undiagnosed or misdiagnosed often causes a delay in treatment at the earliest stage of disease trajectory. (Fromer,2011)

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In addition, looking at the effects of nutrition it’s also important to consider the effects of involving patients’ friends, family and care givers when assessing and planning future care. Some patients might find it difficult sharing their personal information to health care professionals in front of loved ones about their condition, due to sensitive information that might be exposed or harbouring guilt from either a history of smoking or not seeking treatment earlier (Fromer, 2011). When completing an assessment and planning care for patients it is important to consider and maintain patient confidentiality, valid consent must be gained from the patient before any information I shared outside of the nurse patient relationship. (MNC, 2018)

NUTRITION

The poor prognostic sight in COPD is the fact, that many patients with COPD are underweight. According to Currie (2017), malnutrition is associated with the severity of airflow obstruction. Good assessment, getting background information on a patient’s breathlessness, daily activities it’s important to maintain good nutrition status. Lack of information in assessment increasing patient’s risk to become malnourished rapidly due to lack of energy from poor nutrition. All those aspects will have an impact on skin condition as well down to poor mobility because of lack of energy. This factors at an early assessment will help improve a patient’s quality of life and help preventing from condition getting worsted (Former, 2011).                                                                                                     In addition, looking at nutrition it also important to select an appropriate nutritional screening tool   to be used during the assessment, for example the Malnutrition Universal Screening Tool, known as MUST (BAPEN, 2011). Other tool, less known is the Mini Assessment Tool, known as MNA, common in assessment in older adults (Nestle Nutrition Institute, 2009). It is very important to inform the patient about the reason for that procedure as well as obtain consent and using appropriate communication methods. The nurse, and other health professionals should be aware that effective nutritional assessment begins on first contact with the patient. It may be admission in hospital etc. Supporting patient’s nutritional requirements is a fundamental aspect of nursing care. During the initial nutritional assessment patient’s high and weight need to be obtain using calibrated weighing scale and a height measure; this information will enable the selected nutritional screening tool to be completed. If this is not possible, calculate the patient’s mid-upper arm circumference by measuring the ulna length an upper arm circumference with a tape measure, as described in the MUST (BAPEN,2011). It is important for nurses and carers to remember that patient s who are underweight or overweigh can be malnourished. However, malnutrition patients who are obese is more likely to be related to a diet deficient in essential nutrients, such as vitamins, and minerals, rather then protein energy undernutrition. Protein energy undernutrition develops when nutritional intake is not enough to meet demand; for example, when patients has a difficulty to access food. In this scenario, the condition can develop during acute or critical illness because of metabolic demand (Price,2008).  The Council of Europe (2003) developed a resolution on food and nutritional care in hospitals, which identified ten characteristics of optimal nutritional care in hospital, including the requirement for screening for malnutrition on admission and weekly thereafter, and the development of a care plan which highlights the patient’s nutritional requirements and how to put them in live. The people which are at high risk of developing malnutrition extends beyond those with chronic, progressive conditions in this case its COPD. The risk of developing malnutrition can be quantified with the MUST tool (BAPEN 2011), which can indicate the necessity for referral to other part of multidisciplinary team, for example to dietitian, and address the implementation of an individualised needs and help create care plan. In addition, looking at the effects of nutrition it’s also important to consider the effects of involving patients’ friends, family and care givers when assessing and planning future care. Some patients might find it difficult sharing their personal information to health care professionals in front of loved ones about their condition, due to sensitive information that might be exposed from either a history of smoking or not seeking treatment earlier (Fromer,2011).                                                                                                                Willis (2017) observed and noted that in an essential element of any assessment, nurse’s ability to identify the sings and symptoms of malnutrition will develop with increased interaction with the patient. The MUST (BAPEN, 2011) identifies unintentional weight loss as an indicator of risk; however, not all the issues that affecting or can affect a patient’s, person’s ability to maintain their nutritional health will be identified using a screening tool. When risk is identified accurately can also relay on previous knowledge (if present) of the patient and information gained from the patient and information gained from the patient or their carer. Booker et al (2011) discussed the importance of undertaking an initial nursing assessment to identify the patient’s dietary history and changes in appetite, as well as thinking about individual lifestyle issues such as  the patient’s ability to get shopping, the distance they have to travel, as well where they live, with whom  they live or do they have any help and the most important the effect of limited budgets on nutrition (Wills, 2017). Wills (2017) highlighted that frailty in older people and social isolation must also be consider as they will affect nutritional intake. However, it is important to remember that frailty is not an inevitable consequence of ageing and a good assessment of nutritional risk can improve health outcomes since it enables the health care professionals to implement dietary interventions that can improve nutritional intake (Wallington,2016).                                                               As mentioned before, unintentional weight loss is associated with increased rates of mortality and morbidity; however, it is not always possible to identify a clear pathophysiological cause (Gaddey et al 2014).

(Hodson and Blimires, 2015) Implies if a COPD patient had recently lost any weight or unintentionally gained, holistically assessing patients for muscle fatigue, oedema, hypersecretion and bronchoconstriction, Respiratory muscle fatigue can lead to hypoxaemia, hypercapnia and respiratory acidosis, Hypoxia and acidosis can lead to peripheral oedema.(Currie,2017) When screening with the MUST tool it may still show as a healthy weight, it wouldn’t show factors such as unexplained weight gain, shortness of breath, whether a person is able to still undertake their normal activities at their normal level of exertion, MUST also doesn’t identify factors such as age related changes in posture, ratio of body mass Index (BMI) and breathlessness. It is estimated between 10-45% of those with COPD within the community are at risk of malnutrition (Stratton et al, 2003). Malnutrition can often be identified by using the universal tool for measuring Body Mass Index (BMI) and Malnutrition Universal Screening Tool (MUST) flowchart (Stratton et al, 2003) .Whereas an assessment tool such as BORG, identifies a person’s ability to perform certain tasks and activities within their activities of daily living, while assessing their breathlessness level on exertion. Although this assessment tool is commonly used for those with COPD, it doesn’t identify if a person had lost or gained weight and become malnourished. By combing several tools together like the MUST and MNA (Nestle Nutrition Institute, 2009). When considering if a patient is malnourished following national guidance and pathways from National Institute Clinical Excellence (NICE, 2016) guidelines and Department of Health,(DOH, 2010) While on admission patients often have decreased mobility and reduction of their daily activities which can result in increased complications such as co-mobilities, decrease quality of life, while also influencing their emotional well-being and disease trajectory (Collins et al, 2010).   When completing an assessment and planning care for patients it is important to consider and maintain patient confidentiality, valid consent must be gained from the patient before any information I shared outside of the nurse patient relationship. (MNC, 2018).                                                                                                                         Understanding patient’s perception of their illness is an important first step to providing comprehensive, multifaceted care for patients with long term conditions                                                                                                                                            Overall, evidence supports the use of a screening tool when undertaking a nutritional assessment. However, Young et al (2013) also found little significant variation between nutritional screening tool, which shown that no single tool used, is more important to enable accurate assessment of patient’s nutritional status .Therefore, the continued  use of the MUST (BAPEN, 2011) in the UK can be recommended, although the use of alternative such as the MNA ( Nestle Nutrition Institute, 2009), or BMI can also adequately identify nutritional risk. It is important to support adult patients with their nutritional requirements; it can be in hospital or community. The nurses should use a structured approach to assess the patient’s nutritional status.

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