Lewis’s Medical–Surgical Nursing

Assessment and Management of Clinical Problems

3rd edition

6 Community-based nursing care 92Teri A Murray (US); Debbie Kralik (ANZ)

7 Complementary and alternative therapies 105Virginia Shaw (US); Lesley Cuthbertson (ANZ)

8 Pain management 126Mary Ersek, Gordon A Irving (US); Di Brown (ANZ)

9 Palliative care 158Margaret McLean Heitkemper, Cheryl Ross Staats (US); Ann Harrington, Meg Hegarty (ANZ)

10 Substance use and dependency 173Patricia Graber O’Brien (US); Charlotte de Crespigny, Peter Athanasos (ANZ)

The ‘Suite’ 00Navigate by Colour/How to use this Book 00Preface 00Acknowlegdements 00Contributors 00Reviewers 00

SECTION ONEConcepts in nursing practicePaul Morrison

1 The importance of nursing 2Patricia Graber O’Brien (US); Mary FitzGerald, John Field (ANZ)

2 Culturally competent care 22Cory A Shaw, Margaret M Andrews (US); Frances Hughes, Lesley Seaton (ANZ)

3 Health history and physical examination 36Patricia Graber O’Brien (US); Jan Thompson (ANZ)

4 Health promotion and patient education 49Patricia Graber O’Brien (US); Pauline Glover (ANZ)

5 Older adults 64Margaret Wooding Baker, Margaret McLean Heitkemper (US); Lynn Chenoweth (ANZ)

Contents

vi CONTENTS

Stimulants 176

Depressants 183

Cannabis 188Hallucinogens 189Inhalants (solvents) 189

11 Rural and remote area nursing 208Sue Kruske, Sue Lenthall, Sue Kildea, Sabina Knight, Beverley Mackay, Desley Hegney (ANZ)

SECTION TWOPathophysiological mechanisms of diseasePatsy Yates

12 Nursing management: inflammation and wound healing 224Russell Zaiontz, Sharon L Lewis (US); Patsy Yates (ANZ)

13 Genetics, altered immune responses and transplantation 246Sharon L Lewis (US); Patsy Yates (ANZ)

14 Nursing management: infection and human immunodeficiency virus infection 277Jeffrey Kwong, Lucy Bradley-Springer (US); Patsy Yates (ANZ)

15 Cancer 306Jormain Cady, Joyce Marrs (US); Patsy Yates (ANZ)

16 Nursing management: fluid, electrolyte and acid–base imbalances 349Audrey J Bopp (US); Patsy Yates (ANZ)

Fluid and electrolyte imbalances 356

Central venous access devices 376

SECTION THREEPerioperative careSonya Osborne

17 Nursing management: preoperative care 384Janice A Neil (US); Carolyn Naismith (ANZ)

CONTENTS vii

18 Nursing management: intraoperative care 402Anita J Shoup, Maureen Reilly, Jack R Kless (US); Sonya Osborne (ANZ)

19 Nursing management: postoperative care 421Debra J Smith (US); Carolyn Naismith (ANZ)Postoperative management in the postanaesthesia recovery

unit 421

Care of the postoperative patient in the surgical unit 430

SECTION FOURProblems related to altered sensory inputNick Santamaria

20 Nursing assessment: visual and auditory systems 444Sarah C Smith, Sherry Neely (US); Karen Twyford (ANZ)The visual system 444

The auditory system 458

21 Nursing management: visual and auditory problems 468Sarah C Smith, Sherry Neely (US); Karen Twyford (ANZ)Visual problems 468

Extraocular disorders 474

Intraocular disorders 478

Auditory problems 491External ear and canal 491

Middle ear and mastoid 494

Inner ear problems 497

22 Nursing assessment: integumentary system 507Barbara Sinni-McKeehen (US); Nick Santamaria (ANZ)

23 Nursing management: integumentary problems 518Barbara Sinni-McKeehen, Elise F Hazzard (US); Nick Santamaria (ANZ)

Malignant skin neoplasms 520

Dermatological problems 524

viii CONTENTS

Multidisciplinary care: dermatological problems 529

24 Nursing management: burns 543Judy A Knighton (US); Joy Fong (ANZ)

Phases of burn management 548

SECTION FIVEProblems of oxygenation: ventilationBridie Kent

25 Nursing assessment: respiratory system 572Jane Steinman Kaufman (US); Bridie Kent (ANZ)

26 Nursing management: upper respiratory tract problems 597Valerie Bender Howard (US); Jane Clarke (ANZ)Structural and traumatic disorders of the nose 597

Inflammation and infection of the nose and paranasal sinuses 599

Diseases and disorders of the paranasal sinuses 605

Problems related to the pharynx 605

Problems related to the trachea and larynx 607

27 Nursing management: lower respiratory tract problems 625Janet T Crimlisk (US); Jane Clarke (ANZ)Lower respiratory tract infections 625

Chest trauma and thoracic injuries 650

Restrictive respiratory disorders 660

Interstitial lung diseases 663

Vascular lung disorders 663

Pulmonary hypertension 666

28 Nursing management: obstructive pulmonary diseases 673Jane Steinman Kaufman (US); Bridie Kent (ANZ)

SECTION SIXProblems of oxygenation: transportMaryanne Hargraves

29 Nursing assessment: haematological system 730Brenda K Shelton, Sandra Irene Rome, Sharon L Lewis (US); Maryanne Hargraves (ANZ)

CONTENTS ix

30 Nursing management: haematological problems 751Sandra Irene Rome (US); Maryanne Hargraves (ANZ)

Anaemia caused by decreased erythrocyte production 755

Anaemia caused by blood loss 761

Anaemia caused by increased erythrocyte destruction 762

Problems of haemostasis 768

Lymphomas 790

SECTION SEVENProblems of oxygenation: perfusionRobyn Gallagher

31 Nursing assessment: cardiovascular system 808Angela J DiSabatino, Linda Bucher (US); Linda Soars (ANZ)

32 Nursing management: hypertension 831Elisabeth G Bradley (US); Robyn Gallagher (ANZ)

33 Nursing management: coronary artery disease and acute coronary syndrome 854Linda Griego Martinez, Linda Bucher (US); Robyn Gallagher (ANZ)Coronary artery disease 854

Acute coronary syndrome 874

Sudden cardiac death 890

34 Nursing management: heart failure 894Mary Ann House-Fancher, Hatice Y Foell (US); Linda Soars (ANZ)

35 Nursing management: ECG monitoring and arrhythmias 914Linda Bucher (US); Robyn Gallagher (ANZ)

36 Nursing management: inflammatory and structural heart disorders 939Nancy Kupper, De Ann Mitchell (US); Robyn Gallagher (ANZ)Inflammatory disorders of the heart 939

Valvular heart disease 952

Cardiomyopathy 959

x CONTENTS

37 Nursing management: vascular disorders 967Deidre D Wipke-Tevis, Kathleen Rich (US); Linda Soars (ANZ)Peripheral arterial disease 967

Disorders of the aorta 968

Disorders of the veins 983

SECTION EIGHTProblems of ingestion, digestion, absorption and elimination Ann Framp

38 Nursing assessment: gastrointestinal system 998Anne Croghan (US); Marie Verschoor (ANZ)

39 Nursing management: nutritional problems 1023Peggi Guenter (US); Di Brown (ANZ)

40 Nursing management: obesity 1052Jennifer Kretzschmar, Paula Blackwell, Sharon L Lewis (US); Brighid McPherson (ANZ)

41 Nursing management: upper gastrointestinal problems 1073Margaret McLean Heitkemper (US); Ann Framp (ANZ)

Oesophageal disorders 1081

Disorders of the stomach and upper small intestine 1091

42 Nursing management: lower gastrointestinal problems 1121Marilee Schmelzer (US); Stephanie Buckton (ANZ)

Chronic abdominal pain 1133

Inflammatory disorders 1135

Malabsorption syndrome 1167

CONTENTS xi

Anorectal problems 1171

43 Nursing management: liver, pancreas and biliary tract problems 1176Margaret McLean Heitkemper, Anne Croghan, Paula Cox-North (US); Ann Framp (ANZ)

Disorders of the liver 1177

Disorders of the pancreas 1207

Disorders of the biliary tract 1217

SECTION NINEProblems of urinary functionAnn Bonner

44 Nursing assessment: urinary system 1226Vicki Y Johnson (US); Ann Bonner (ANZ)

45 Nursing management: renal and urological problems 1249Vicki Y Johnson (US); Ann Bonner (ANZ)Infectious and inflammatory disorders of urinary

system 1249

Immunological disorders of the kidney 1259

Obstructive uropathies 1262

Renal trauma 1270Renal vascular problems 1270

Hereditary renal diseases 1270

Renal involvement in metabolic and connective tissue diseases 1272

Urinary tract tumours 1272

Surgery of the urinary tract 1284

46 Nursing management: acute kidney injury and chronic kidney disease 1292Carol M Headley (US); Ann Bonner (ANZ)

Dialysis 1313

SECTION TENProblems related to regulatory and reproductive mechanismsJenny Sando

47 Nursing assessment: endocrine system 1336JoAnne Konick-McMahan (US); Valerie Cheetham (ANZ)

xii CONTENTS

48 Nursing management: diabetes mellitus 1357Nancy C Robbins, Cory A Shaw, Sharon L Lewis (US); Bronwyn Davis (ANZ)Diabetes mellitus 1357

Acute complications of diabetes mellitus 1381

Chronic complications of diabetes mellitus 1386

49 Nursing management: endocrine problems 1396JoAnne Konick-McMahan (US); Valerie Cheetham (ANZ)Disorders of the anterior pituitary gland 1396

Disorders associated with antidiuretic hormone secretion 1400

Disorders of the thyroid gland 1403

Disorders of the parathyroid glands 1416

Disorders of the adrenal cortex 1419

Disorders of the adrenal medulla 1428

50 Nursing assessment: reproductive system 1431Shannon Ruff Dirksen (US); Julie Parry (ANZ)

51 Nursing management: breast disorders 1453Cynthia Matthews (US); Marion Strong (ANZ)

Benign breast disorders 1456

52 Nursing management: sexually transmitted infections 1479Shari Goldberg (US); John Rolley (ANZ)

Bacterial infections 1480

ChlamydiaViral infections 1487

53 Nursing management: female reproductive problems 1496Nancy J MacMullen, Laura Dulski (US); Julie Parry (ANZ)

Problems related to menstruation 1500

CONTENTS xiii

Conditions of the vulva, vagina and cervix 1508

Benign tumours of the female reproductive system 1512

Cancers of the female reproductive system 1514

Problems with pelvic support 1522

54 Nursing management: male reproductive problems 1530Shannon Ruff Dirksen (US); John Rolley (ANZ)Problems of the prostate gland 1530

Problems of the penis 1546

Problems of the scrotum and testes 1548

Sexual functioning 1550

SECTION ELEVENProblems related to movement and coordinationJacqueline Baker

55 Nursing assessment: nervous system 1560Sherry Garrett Hendrickson (US); Jacqueline Baker (ANZ)

56 Nursing management: acute intracranial problems 1588Linda Laskowski-Jones (US); Jacqueline Baker (ANZ)

Inflammatory conditions of the brain 1615

57 Nursing management: the patient with a stroke 1622Julie T Sanford (US); Sonia Matiuk (ANZ)

58 Nursing management: chronic neurological problems 1646Sherry Garrett Hendrickson, Stephanie A Elms, Virginia Shaw (US); Jacqueline Baker (ANZ)Headache 1646

Chronic neurological disorders 1652

Other neurological disorders 1674

59 Nursing management: delirium, dementia and Alzheimer’s disease 1678Virginia Shaw, Sharon L Lewis (US); Wendy Moyle (ANZ)

60 Nursing management: peripheral nerve and spinal cord problems 1698Linda Laskowski-Jones (US); Anna Brown (ANZ)Cranial nerve disorders 1698

xiv CONTENTS

Polyneuropathies 1703

Spinal cord problems 1707

61 Nursing assessment: musculoskeletal system 1734Dottie Roberts (US); Aileen Wyllie (ANZ)

62 Nursing management: musculoskeletal trauma and orthopaedic surgery 1749Sharon G Childs (US); Aileen Wyllie (ANZ)Soft-tissue injuries 1749

Fractures 1755

Complications of fractures 1769

Types of fractures 1772

Common joint surgical procedures 1782

63 Nursing management: musculoskeletal problems 1789Colleen R Walsh (US); Aileen Wyllie (ANZ)

Low back pain 1796

Neck pain 1805Foot disorders 1805

Metabolic bone diseases 1807

64 Nursing management: arthritis and connective tissue diseases 1815Dottie Roberts (US); Di Brown (ANZ)Arthritis 1815

Spondyloarthropathies 1834

Soft-tissue rheumatic syndromes 1850

SECTION TWELVENursing care in specialised settingsThomas Buckley and Christopher Gordon

65 Nursing management: critical care environment 1858Linda Bucher, Maureen A Seckel (US); Thomas Buckley (ANZ)

CONTENTS xv

66 Nursing management: shock and multiple organ dysfunction syndrome 1898Kathleen M Geib (US); Margherita Murgo (ANZ)

67 Nursing management: respiratory failure and acute respiratory distress syndrome 1926Richard B Arbour (US); Christopher Gordon (ANZ)

68 Nursing management: emergency care situations 1950Linda Bucher (US); Elizabeth Leonard (ANZ)

Environmental emergencies 1958

69 Chronic illness and complex care 1979Linda Soars, Robyn Gallagher (ANZ)

APPENDICESA Cardiopulmonary resuscitation and basic life

support 1995

B Nursing diagnoses 2001

C Answer key to review questions 2003

Picture credits 2005

Index 0000

1950

Chapter 68

Population and social change

Cost and access

Assessment of the emergency patient

triage

LEARNING OBJECTIVES

1 Understand the principles of patient assessment in the emergency department, including triage, primary survey and secondary survey.

2 Differentiate between the various types and victims of violence: accidental versus abuse (domestic violence and children at risk).

3 Recognise the significance of ‘mechanism of injury’ and initial signs and symptoms for identifying actual or potential traumatic injury.

4 Describe the pathophysiology, assessment and multidisciplinary care of select environmental emergencies, including hyperthermia, hypothermia and submersion injury.

5 Identify a selection of Australia’s venomous creatures and discuss the principles of management for envenomation.

6 Explain the principles of care for select toxicology emergencies. 7 Explore the strategies of preparedness for the management of major incidents,

emergency and/or disaster. 8 Describe the toxic agents and the principles of management for chemical, biological

and radiation hazards.

KEY TERMS

chemical, biological and radiation (CBR) hazards, p 1974

children at risk, p 1956disaster, p 1972domestic violence, p 1956emergency, p 1972envenomation, p 1965frostbite, p 1962heat cramps, p 1959heat exhaustion, p 1960heat stroke, p 1961hyperthermia, p 1959hypothermia, p 1961jaw-thrust or chin-lift manoeuvre, p 1953major incident, p 1972mechanism of injury, p 1956primary survey, p 1951rapid-sequence induction, p 1953secondary survey, p 1954submersion injury, p 1963toxicology, p 1969triage, p 1950

NURSING MANAGEMENT:

emergency care situationsWritten by Linda Bucher

Adapted by Elizabeth Leonard

1972 SECTION 12 Nursing care in specialised settings

Haemodialysis and haemoperfusion

Antidote administration

PSYCHOLOGICAL SUPPORT

Major incident and disaster preparedness

major incident

Civil Defence Emergency Management Act 2002

emergency disaster

Community Welfare Act 1987

CHAPTER 68 NURSING MANAGEMENT: emergency care situations 1973

EMERGENCY SERVICES

Figure 68-8 Transferring an injured person to hospital.

Source: Photolibrary.

Figure 68-9 Severe crush injuries may result from the damage caused by an earthquake, such as the recent Christchurch earthquake.

Source: Photolibrary.

Figure 68-10 Emergency management of victims from the Bali terrorist attack.

Source: Used with permission. Royal Darwin Hospital, Clinical Photo Library.

1974 SECTION 12 Nursing care in specialised settings

Chemical, biological and radiation hazardsChemical, biological and radiation (CBR) hazards

TABLE 68-10 Chemical agents of terrorism by target organ or effect

Nerve Blood Pulmonary Blister/vesicants

Sarin (isopropyl methylphosphonofluoridate)Tabun (ethyl N,N-dimethylphosphoramido-

cyanidate)Soman (pinacolyl methylphosphonofluoridate)GF (cyclohexyl methylphosphonofluoridate)VX (O-ethyl S-[2-diisopropylaminoethyl]

methylphosphonothiolate)

Hydrogen cyanideCyanogen chloride

PhosgeneChlorineVinyl chloride

Nitrogen and sulfur mustardsLewisite (an aliphatic arsenic

compound, 2-chlorovinyl-dichloroarsine)

Phosgene oxime

Figure 68-11 Patient injuries from the Bali terrorist attack. Note triage assessment.

Source: Used with permission. Royal Darwin Hospital, Clinical Photo Library.

Figure 68-12 Penetrating wounds received as a result of a bomb blast.

Source: Used with permission. Royal Darwin Hospital, Clinical Photo Library.

Figure 68-13 Chest X-ray showing ball-bearing bomb injury.

Source: Used with permission. Royal Darwin Hospital, Clinical Photo Library.

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6. A chemical spill has occurred in a nearby industrial site. The first responders report that approximately 20 victims need to be transported to the emergency department after decontamination at the site. This is an example of:A a major incidentB a natural disasterC a disasterD an emergency

7. Which of the following biological agents has no effective treatment?A anthraxB botulismC smallpoxD Ebola virus

References

Review questions

1. An elderly man arrives at the emergency department. He is tachypnoeic and disoriented, and his skin is hot and dry. The priority for treatment at this point is to:A assess his airway, breathing and circulationB obtain a detailed medical history from his familyC obtain a urine specimen for urinalysisD start oxygen administration and medical assessment

2. A patient has presented with a core temperature of 32.2°C. The most appropriate rewarming technique would be:A passive rewarming with body-to-body contactB active core rewarming using warmed intravenous fluidsC passive rewarming using air-filled warming blanketsD active external rewarming by submersing in a warm

bath3. The recommended management for reducing the

absorption of many ingested poisons is:A ipecac syrupB milk dilutionC gastric lavageD activated charcoal

4. What is the recommended immediate management for a funnel-web spider bite?A tourniquet above the bite site to prevent venom

reaching the central circulationB ice pack to the bite site to reduce pain and decrease

circulation to the bite area, immobilising the venomC direct pressure over the bite site and a firm crepe

bandage over the site then up the entire limbD two ampoules of funnel-web spider antivenom,

administered with prophylaxis for possible allergic reaction

5. In the absence of significant clinical signs and symptoms, what information would lead nursing and medical staff to suspect the potential for underlying injury and the need for trauma team management?A an adult falling 2 mB motor cyclist in a collision with a car at 40 km/hC burns to 10% body surface areaD pedestrian killed by a car

CASE STUDY

The trauma patient

Patient profileA 20-year-old female trauma patient is brought to the emergency department in an ambulance. She was the driver in a motor vehicle collision and was not wearing a seat belt. Two children in the car were pronounced dead at the scene. The paramedics stated that there was significant damage to the car on the driver’s side.

Subjective dataPatient asks, ‘What happened? Where are the children?’Complains of shortness of breath and abdominal pain

Objective dataPhysical examination

4 cm head lacerationBadly deformed right lower leg with a pedal pulse by Doppler onlyGlasgow Coma Scale score = 14, unequal pupilsDecreased breath sounds on left side of chest

Asymmetrical chest movementVital signs: blood pressure 90/40 mmHg, heart rate 130 beats/min, respiratory rate 36 breaths/minO2 saturation 82%

CRITICAL THINKING QUESTIONS

1. What life-threatening injury does this patient probably have?2. What is the priority of care?3. What interventions are needed immediately?4. What other interventions should the nurse consider?5. Several family members have arrived in the emergency

department, including a woman who states her child was in the car (one of the children who died). The second child who died was the patient’s child. How should the nurse approach the family?

6. Based on assessment data presented, write one or more nursing diagnoses. Are there any collaborative problems?

1979

Chapter 69

Chronic illnessChronic illnesses

ā

The complexity of chronic illness

exacerbation

LEARNING OBJECTIVES

1 Describe the major causes of chronic illnesses. 2 Explain the characteristics of a chronic illness across the life span. 3 Explore complex illnesses and the assessment of comorbidities in adults. 4 Describe self-management and self-care principles relating to chronic illness

management. 5 Evaluate the models of care used to manage chronic and complex illnesses. 6 Identify the workforce requirements for health workers in meeting needs for chronic

illness management.

KEY TERMS

care coordination, p 1986care navigation, p 1985case management, p 1989chronic illnesses, p 1979 disease management, p 1982exacerbation, p 1979self-efficacy, p 1985self-management, p 1982social cognitive theory, p 1982

Chronic illness and complex careWritten by Linda Soars and Robyn Gallagher

1980 SECTION 12 Nursing care in specialised settings

ā

ā

ā

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Health

Illness MonthsTIME

OnsetStable Stable

Stable

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Downward

Dying

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k

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Figure 69-1 The chronic illness trajectory is a theoretical model of chronic illness. The trajectory model of chronic illness recognises that chronic illness will have many phases (see Table 69-1).

TABLE 69-1 Chronic illness trajectory

Phase Description

Onset Signs and symptoms are presentDisease diagnosed

Stable Illness course/symptoms controlled by regimen Individual maintains everyday activities

Acute Active illness with severe and unrelieved symptoms or complications

Hospitalisation required for managementComeback Gradual return to an acceptable way of lifeCrisis Life-threatening situation occurs

Emergency services are necessaryUnstable Unable to keep symptoms/disease course

under control Life becomes disrupted while working to regain stability

Hospitalisation not requiredDownward Gradual and progressive deterioration in

physical/mental status Accompanied by increasing disability and symptoms

Continuous alterations in everyday life activitiesDying Individual has to relinquish everyday life

interests and activities, let go and die peacefully Immediate weeks, days, hours preceding death

Source: Woog P. The chronic illness trajectory framework: the Corbin and Strauss nursing model. New York: Springer; 1992.

CHAPTER 69 Chronic illness and complex care 1981

Management of chronic illnessMODELS OF CHRONIC ILLNESS CARE

self-management

Patient and family assessment

BOX 69-1 Social support and self-care recommendations to improve outcomes using carers

Social support provided by partners of a quality and content that matches heart failure patients’ needs is associated with better self-care, particularly in the key areas of taking medications, managing fluid intake, consulting health professionals for weight gain, having a flu shot and taking regular exercise. When assessing heart failure patients’ capacity for self-care, the partner’s relationship with the patient should also be assessed.Carers, especially partners, should be considered as integral to the treatment and care of heart failure patients. New teaching or counselling strategies are needed to optimise self-care in heart failure patients and their partners.

Source: Gallagher R, Luttik M, Jaarsma T. Social support and self-care in heart failure. J Cardiovasc Nurs 2011; 2.

1982 SECTION 12 Nursing care in specialised settings

PRINCIPLES OF SELF-MANAGEMENT

Self-management

disease management

social cognitive theory

TABLE 69-2 Models of care

Service type Model Rationale for use

Emergency department Fast-track for lower triage categoriesAdmission using 3-2-1 time limitClinician initiative nurses (CINs)Nurse practitionersAged care services in emergency team Nurse protocolsEmergency medical unitPsychiatric emergency care centre

A large number of models have been tried around the world to improve the flow of people with an unplanned health crisis through the emergency system. A triage process is used in all emergency departments to ensure care by need, but there is also benefit in treating and discharging people with problems that can be managed in the community via alternative care pathways.

Inpatient services Chest painClinical decisionShort stayAssessment unit: medical/aged care/surgical

Once admitted, patients receive targeted assessments, reviews and interventions designed to be given within a time-limited period. They are discharged earlier and receive appropriate ongoing care at home.

Hospital-in-the-home services Acute short-term medical, nursing and allied health services.

Slow stream rehabilitation services—transitional care support.

Patients receive care in their own homes that would usually be delivered in a hospital setting.

Community-based services Chronic disease rehabilitationSelf-management programsShort-term support services offering 2–3 services

(e.g. NSW Compacks)

Offered to individuals and groups to support, educate and rehabilitate people experiencing exacerbations of their chronic illness.

BOX 69-2 Avoiding hospital admissions: what does the evidence tell us?

Interventions with evidence of a positive effect

Reducing admissions

Continuity of care with a general practitionerHospital at home as an alternative to admissionAssertive case management in mental healthSelf-managementEarly senior review in the emergency departmentMultidisciplinary interventions and telemonitoring in heart failureIntegration of primary and secondary care

Reducing readmissions

Structured discharge planningPersonalised healthcare programs

Interventions with evidence of little or no beneficial effectPharmacist home-based medication reviewIntermediate careCommunity-based case management (generic conditions)Early discharge to hospital at home on readmissionsNurse-led interventions pre- and post-discharge for patients with chronic obstructive pulmonary disease

Interventions for which further evidence is neededIncreasing the size of general practice surgeriesChanging out-of-hours primary care arrangementsChronic care management in primary careTelemedicineCost-effectiveness of general practitioners in the emergency departmentAccess to social care in the emergency departmentHospital-based case managementRehabilitation programsRapid response teams

Source: Purdy S. Avoiding hospital admissions: what does the research evidence say? The King’s Fund response to the Department of Health’s public consultation on an information revolution. London: King’s Fund; 2010.

CHAPTER 69 Chronic illness and complex care 1983

REQUIREMENTS FOR SELF-MANAGEMENT

Dealing with chronic illness

Maintaining a ‘normal’ life

Dealing with emotions

TABLE 69-3 A systematic review of disease management interventions for patients with chronic heart failure

Intervention Approach Evidence

Multidisciplinary interventions A holistic approach bridging the gap between hospital admission and discharge, delivered by a team

Overall concept embedded in multidisciplinary teams—supports an interprofessional, collaborative approach to health service provision.

Case management interventions Intense monitoring of patients following discharge, often involving telephone follow-up and home visits

Case management in the community and in hospital is not effective in reducing generic admissions. There is limited evidence to suggest that it may be effective for patients with heart failure. Assertive case management is beneficial for patients with mental health problems.

Clinic interventions The general practitioner deals only with chronic diseases for that clinic

Specialised clinics or mini-clinics (where a group delegates a general practitioner to deal with only chronic diseases for that day) were also found to be beneficial. Larger clinics in practices are not necessarily associated with lower levels of emergency admissions.

Source: Purdy S. Avoiding hospital admissions: what does the research evidence say? The King’s Fund response to the Department of Health’s public consultation on an Information Revolution. London: King’s Fund; 2010.

1984 SECTION 12 Nursing care in specialised settings

Heart & lung health team

Multidisciplinary community chronic heart care plan

Patient name ______________________________________________Date of birth _______________ AUTHORITY TO PROCEED WITH CARE PLAN: My GP/health professional has explained the purpose of a care plan. I give my permission to prepare a care plan and discuss my medical history and diagnosis with the members of a multidisciplinary team. I do/do not request specific medical or other information to be withheld from other participants (noted in medical records). I am aware that there is a fee for the preparation of this care plan and a Medicare rebate will be payable.Patient signature ___________________________________________Date _____________________

Assessment of health needs Management goals Action required Provider Review date

Symptom management To understand and encourage self-management of symptoms

Education about heart failure Symptom monitoring Refer to cardiologist for assessment for cardiac rehabilitation

Flexible diuretic regimen

General practitioner, clinical nurse specialist and heart & lung health team

Management of fluid retention To encourage self-monitoring of increased fluid retention

Education about daily weights decreased sodium intake fluid restriction

Dietician, clinical nurse specialist and heart & lung health team

Modification of activities of daily living (ADLs)

To encourage independence in ADLs

Occupational therapy assessment

Community nursing assessment

Occupational therapist andcommunity nurse

Medication management To understand and comply with medication regimen

Community pharmacist or specialist nurse assessment

General practitioner and pharmacist

Psychosocial support To manage anxiety and avoid significant depression

Counselling Refer to positive living group

Social worker and group coordinator

Increase physical activity To gradually increase activity tolerance

Education about daily graded exercise

Refer to CCF/COPD group

Exercise physiologist, clinical nurse specialist and heart & lung health team

Patient health goals and motivation

Patient to provide health goals in own words

Discuss and write patient’s goals to allow measurement over time

Exercise physiologist, clinical nurse specialist and heart & lung health team

Additional needs

I agree to the above care plan and understand the recommendations.Patient signature ___________________________________________GP signature _______________________________________________Date __________________________SERVICE PROVIDERS: I have received and agree with this care plan.Name and contact details __________________________________________________________________________________________________Date ___________________________________________Name and contact details __________________________________________________________________________________________________Date ___________________________________________Name and contact details __________________________________________________________________________________________________Date ___________________________________________Name and contact details __________________________________________________________________________________________________Date ___________________________________________Copy to patient YES/NO Copy to service providers YES/NO CARE PLAN REVIEW DATE ____________________________

Figure 69-2 Sample care plan for a patient with chronic heart disease.

CHAPTER 69 Chronic illness and complex care 1985

care navigators

CARE NAVIGATIONCare navigation

SELF-EFFICACY IN SELF-MANAGEMENT

self-efficacy

ENCOURAGING SELF-MANAGEMENT

1986 SECTION 12 Nursing care in specialised settings

Patient name ___________________________________________________________________ Date of birth ___________________________AUTHORITY TO PROCEED WITH CARE PLAN: My GP/health professional has explained the purpose of a care plan. I give my permission to prepare a care plan and discuss my medical history and diagnosis with the members of a multidisciplinary team. I do/do not request specific medical or other information to be withheld from other participants (noted in medical records). I am aware that there is a fee for the preparation of this care plan and a Medicare rebate will be payable.Patient signature _________________________________________________________________ Date __________________________

Assessment of health needs Management goals Action required Provider

Appointment date

Discuss patient self-management goals for diabetes

To define the patient’s goals Discuss current health plan Write patient’s health goals

Diabetes nurse or general practitioner

Assess patient’s confidence and skills to manage diabetes

To observe the patient’s skill set for diabetes management tasks

Assist to set test frequency and ranges for blood sugar level

Diabetes nurse or general practitioner

Assess patient’s lifestyle risks (SNAPW: smoking, nutrition, alcohol intake, physical activity, weight)

To set goals to manage identified risks

Discuss plan and timeframe to manage each risk identified

Diabetes nurse or general practitioner

Assess patient’s coping skills—emotional impact and social support

To measure anxiety and depression levels

Discuss treatment plans Access psychological services

Psychologist/counsellor

Prepare multidisciplinary team care plan as needed

To define the needs for allied health services to support the plan

Refer to allied health workers to collaborate with the care plan

General practitioner

I agree to the above care plan and understand the recommendations.Patient signature ________________________________ GP signature _________________ Date __________________________SERVICE PROVIDERS: I have received and agree with this care plan.Name and contact details __________________________________________________________________________________________________Date ___________________________________________Name and contact details __________________________________________________________________________________________________Date ___________________________________________Name and contact details __________________________________________________________________________________________________Date ___________________________________________Name and contact details __________________________________________________________________________________________________Date ___________________________________________Copy to patient YES/NO Copy to service providers YES/NO CARE PLAN REVIEW DATE ____________________________

CARE COORDINATIONCare coordination

Figure 69-3 Sample self-management care plan for blood sugar levels.

CHAPTER 69 Chronic illness and complex care 1987

Clinical knowledge

Threshold modelling

Predictive modelling

Transitions and care coordination in chronic illness care

Care navigation—guided to the right point of care

Community-based rehab and education Acute hospital servicesSeek out alternative pathways to hospital

admission

Emergency department

Assertive discharge planning for

hospital-in-the-home services, transitional

care services

Chronic disease team

General practitioner

Social and personal support services

Chronic disease self-care

Family and carers

High-risk patient with chronic and

complex disease

Figure 69-4 The care navigation process.

Community Health systems

Improved outcomes

Resources and policies Organisation of healthcare

Deliverysystemdesign

Decisionsupport

Clinicalinformation

systems

Self-management

support

Productiveinteractions

Informed,activepatient

Prepared,proactive

practice team

Figure 69-5 The chronic care model.

Source: The Group Health Research Institute. Available at www.

improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2,

accessed 14 January 2011.

1988 SECTION 12 Nursing care in specialised settings

BOX 69-3 Hospital Admission Risk Profile (HARP) calculator

Part A: clinical assessment

1. Presenting clinical symptoms

Diagnosis of chronic respiratory condition (1)Diagnosis of chronic cardiac condition (1)Diagnosis of complex care needs in frail aged, such as dementia, falls

or incontinence (1)Diagnosis of complex care needs in people less than 55 years of age,

such as mental health illness (1)Comorbid diagnosis of diabetes and/or renal failure and/or liver

disease (1)Score: /5

2. Service access profile

Acute admission/presentation (more than once in the last 12 months) (4)

No regular GP follow up (regular medical check-ups 2 times a year) (3)

Reduced ability to self-care (to the extent it impacts on disease management) (3)

Score: /10

3. Risk factors

Smoking (1)Overweight (guide BMI 26–35) (1)Underweight (guide BMI <19) (1)High cholesterol (total cholesterol >5.5 mmol/L, HDL <1.0 mmol/L,

LDL >2.0 mmol/L) (1)High blood pressure (>140/90 mmHg or on medication for high

blood pressure) (1)Physical inactivity (less than 30 mins/day and 4 days/week) (1)Polypharmacy (>5 medications with difficulty managing them) (1)Score: /7

4. Extenuating factors

Use of services previously (1)Carer stress issues (1)No carer available (1)Cognitive impairment (1)Change to drug regimen (1)Chronic pain (1)Compromised skin integrity (e.g. wounds, pressure area, cellulitis) (1)Exposure to triggers for asthma (1) Score: /8

Total score clinical assessment (A) /30

Part B: factors impacting on self-management

5. Psychosocial factors and demographic issues

Mental health (depression, anxiety or psychiatric problems) Y/NDisability (intellectual, physical, visual, hearing) Y/NAccess to suitable transport to care services Y/NFinancial issues (inability to afford health services and/or

medications) Y/NCALD or Aboriginal health beliefs Y/NIlliterate and/or limited English Y/NUnstable living environment Y/NSocially isolated Y/NDrug and alcohol problems Y/NRate the impact these combined factors have on the person’s ability

to self-manage their condition:No impact (on ability to self-manage) (0)Low impact (on ability to self-manage) (7)High impact (on ability to self-manage) (15)

Score /15

6. Readiness to change assessment (choose one only)

No capacity for self-management (cognitive impairment, end-stage disease) (4)

Pre-contemplation (not ready for change) (3)Contemplation (considering but unlikely to change soon) (3)Preparation (intending to take action in the immediate future) (2)Action (actively changing health behaviours but having difficulties

maintaining plan) (1)Maintenance (maintained behaviour for >6 months) (1)Relapse (a return to the old behaviour) (3)Score: /4

Total score for self-management impact (B) /19

Overall risk: add part A and part B /49

The higher the score, the higher the risk of readmission.

Source: Taylor S, Bestall J, Cotter S, Falshaw M, Hood S et al. Clinical service organisation for heart failure. Cochrane Database Syst Rev 2005; (2).

BOX 69-4 Planning for discharge: essential attributes of discharge interventions that can potentially reduce readmissions

Early and complete assessment of discharge needs and medication reconciliation.Enhanced patient (and carer) education and counselling specifically focused on gaining an understanding of the patient’s condition and its self-management.Timely and complete communication of management plan between clinicians at discharge when patient care is transferred from hospital staff to primary care teams.Early post-acute follow-up within 24–72 h for high-risk patients with either doctor or nurse.Early post-discharge nurse (or pharmacist) phone calls or home visits to confirm understanding of management and follow-up plans in high-risk patients.Appropriate referral for home care and community support services when needed.

Source: Scott I. Preventing the rebound: improving care transition in hospital discharge processes. Australian Health Review 2010; 34:445–451.

CHAPTER 69 Chronic illness and complex care 1991

4. Depression frequently accompanies or may precipitate chronic illness. Depression makes recovery and management more difficult because it can make it harder for people:A to find the energy to eat healthilyB to exercise or take medication regularlyC as it can reduce initiative and affect adherence and

compliance with health action plans D all of the above

5. Measuring carer strain and completing social care assessments are an important part of assessing the impact of these factors for different phases of the chronic illness journey. This is because:A carers have become too focused on their own needs

and have neglected those of the patients under assessment

B there are so many government programs for patient social support that a different assessment has to be completed for each one

C a review of the domestic support needs and carer factors enables the case manager to effectively plan interventions that meet the patient’s goals and needs

D all of the above

Conclusion

Review questions

1. Vos and Carter found that a large impact on improving a population’s health can be achieved by:A taxation of tobacco, alcohol and unhealthy foodsB mandatory limits on salt added during production of

three basic food items (bread, cereals and margarine)C gastric banding for severe obesityD all of the above

2. Many factors contribute to chronic disease complexity and these are characterised by:A periods of exacerbation B the chronic illness and its treatments generating

further issues C the individual with chronic illness experiencing

unequal access to care and supportD all of the above

3. Australian and New Zealand evidence suggests that most of the recent gain in life expectancy for individuals:A is a result of better preschool education and

preparation-for-life classesB is spent accompanied by disability in the final years,

and that much of the extra life years gained are spent with a profound or severe core activity limitation

C is needed to expand the taxation base to pay for healthcare

D is expected by the population due to their higher taxes

CASE STUDY

The patient with chronic illness

Patient backgroundMrs Clare Giardini is a 69-year-old woman who has had three presentations in the last several months with shortness of breath. She lives in her own home with her 2 adult children, one of whom is a specialist paediatric nurse. Mrs Giardini has a history of osteoarthritis, non-insulin-dependent diabetes and asthma. A recent echocardiogram showed systolic dysfunction and a poor left ventricular ejection fraction, and Mrs Giardini is noted to have chronic controlled atrial fibrillation.

Objective dataTemperature: 36.8 C Heart rate: 116 beats per min Blood pressure: 92/60 mmHgCardiac rhythm: atrial fibrillationCardiac system: S1 and S2 present, no murmursRespirations: 32 shallow Lung sounds: crackles in both basesDaily weight: increased by 5 kg over last 2 days

CRITICAL THINKING QUESTIONS

1. What social factors and assessment questions or tools would be useful to use with this patient?

2. Identify the community health and support services that are available in your health district for this patient.

3. What planning and assessments around the transition process from hospital to home would allow this patient to effectively self-manage her conditions at home?

1992 SECTION 12 Nursing care in specialised settings

6. A holistic assessment tool for the patient with chronic illness needs to:A include standardised assessment of the range of carer

and social aspects in the patient’s circle of supportB account for the conflicting symptoms and strategies of

multiple illnessesC be determined by the case manager over time to

establish and advise the patient of priority steps in their health action plan

D all of the above7. Self-management is an umbrella term that encompasses:

A self-care, the specific tasks that people carry out on a day-to-day basis to manage their condition

B disease management provided by specialist health staff to control palliative symptoms

C the use of health interventions, such as medications, without the need to consider the prescriber’s intentions

D only natural therapies that are known to treat the illness

8. Preventing and managing a crisis are vital skills to develop and the patient and family are expected to:A understand how a health crisis can alter their usual

health state B know ways to prevent or modify a threat to their healthC adhere to a prescribed medical regimen D all of the above

9. People with chronic illnesses need to know the signs and symptoms of the onset of a health crisis. Depending on the chronic illness, these signs and symptoms may include:A seizures in a patient with seizure disorderB heart failure in a patient with untreated hypertensionC a change in sputum colour to yellow/green in a person

with emphysemaD all of the above

10. Self-monitoring strategies include the development of an early warning system such as:A calling or visiting the medical practitioner daily in case

something is wrongB measuring daily weights to detect fluid overload for

people with heart failureC not measuring the blood sugar level when feeling wellD all of the above

References

CHAPTER 69 Chronic illness and complex care 1993

Resources

Australian Disease Management Association

Australian Institute of Health & Welfare

Australian Resource Centre for Hospital Innovations

Australian Vascular Biology Society

Cardiac Society of Australia and New Zealand

Cardiomyopathy Association of Australia

Case Management Society of Australia

Chronic Care for Aboriginal People Program

Diabetes Australia

Diabetes New Zealand

Heart Support Australia

International Disease Management Alliance

Juvenile Diabetes Research Foundation

Māori Health

National Heart Foundation of Australia

National Heart Foundation of New Zealand

New Zealand Guidelines Group

New Zealand Ministry of Health