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    Lewis's Medical-Surgical Nursing 3e - Brown & Edwards Lewis's Medical-Surgical Nursing 3e - Brown & Edwards Document Transcript

    • Lewis’sMedical–Surgical Nursing Assessment and Management of Clinical Problems 3rd edition
    • ContentsThe ‘Suite’ 00Navigate by Colour/How to use this Book 00Preface 00Acknowlegdements 00Contributors 00 6 Community-based nursing care 92 Teri A Murray (US); Debbie Kralik (ANZ)Reviewers 00SECTION ONEConcepts in nursing practicePaul Morrison 1 The importance of nursing 2 Patricia Graber O’Brien (US); Mary FitzGerald, 7 Complementary and alternative therapies 105 John Field (ANZ) Virginia Shaw (US); Lesley Cuthbertson (ANZ) 2 Culturally competent care 22 Cory A Shaw, Margaret M Andrews (US); Frances Hughes, Lesley Seaton (ANZ) 8 Pain management 126 Mary Ersek, Gordon A Irving (US); Di Brown (ANZ) 3 Health history and physical examination 36 Patricia Graber O’Brien (US); Jan Thompson (ANZ) 9 Palliative care 158 4 Health promotion and patient education 49 Margaret McLean Heitkemper, Cheryl Ross Staats (US); Patricia Graber O’Brien (US); Pauline Glover (ANZ) Ann Harrington, Meg Hegarty (ANZ) 5 Older adults 64 Margaret Wooding Baker, Margaret McLean Heitkemper (US); Lynn Chenoweth (ANZ) 10 Substance use and dependency 173 Patricia Graber O’Brien (US); Charlotte de Crespigny, Peter Athanasos (ANZ)
    • vi CONTENTS Stimulants 176 15 Cancer 306 Jormain Cady, Joyce Marrs (US); Patsy Yates (ANZ) Depressants 183 Cannabis 188 Hallucinogens 189 Inhalants (solvents) 189 11 Rural and remote area nursing 208 Sue Kruske, Sue Lenthall, Sue Kildea, Sabina Knight, Beverley Mackay, Desley Hegney (ANZ) 16 Nursing management: fluid, electrolyte and acid– base imbalances 349 Audrey J Bopp (US); Patsy Yates (ANZ) Fluid and electrolyte imbalances 356 SECTION TWO Pathophysiological mechanisms of disease Patsy Yates 12 Nursing management: inflammation and wound healing 224 Russell Zaiontz, Sharon L Lewis (US); Patsy Yates (ANZ) 13 Genetics, altered immune responses and transplantation 246 Sharon L Lewis (US); Patsy Yates (ANZ) Central venous access devices 376 SECTION THREE Perioperative care Sonya Osborne 17 Nursing management: preoperative care 384 Janice A Neil (US); Carolyn Naismith (ANZ) 14 Nursing management: infection and human immunodeficiency virus infection 277 Jeffrey Kwong, Lucy Bradley-Springer (US); Patsy Yates (ANZ)
    • CONTENTS vii18 Nursing management: intraoperative care 402 21 Nursing management: visual and auditory Anita J Shoup, Maureen Reilly, Jack R Kless (US); problems 468 Sonya Osborne (ANZ) Sarah C Smith, Sherry Neely (US); Karen Twyford (ANZ) Visual problems 468 Extraocular disorders 47419 Nursing management: postoperative care 421 Debra J Smith (US); Carolyn Naismith (ANZ) Postoperative management in the postanaesthesia recovery unit 421 Intraocular disorders 478 Auditory problems 491 External ear and canal 491 Care of the postoperative patient in the surgical unit 430 Middle ear and mastoid 494 Inner ear problems 497 22 Nursing assessment: integumentary system 507 Barbara Sinni-McKeehen (US); Nick Santamaria (ANZ)SECTION FOURProblems related to altered sensory inputNick Santamaria 23 Nursing management: integumentary problems 518 Barbara Sinni-McKeehen, Elise F Hazzard (US);20 Nursing assessment: visual and auditory Nick Santamaria (ANZ) systems 444 Sarah C Smith, Sherry Neely (US); Karen Twyford (ANZ) Malignant skin neoplasms 520 The visual system 444 Dermatological problems 524 The auditory system 458
    • viii CONTENTS Multidisciplinary care: dermatological problems 529 27 Nursing management: lower respiratory tract problems 625 Janet T Crimlisk (US); Jane Clarke (ANZ) 24 Nursing management: burns 543 Lower respiratory tract infections 625 Judy A Knighton (US); Joy Fong (ANZ) Phases of burn management 548 Chest trauma and thoracic injuries 650 SECTION FIVE Problems of oxygenation: ventilation Bridie Kent 25 Nursing assessment: respiratory system 572 Jane Steinman Kaufman (US); Bridie Kent (ANZ) Restrictive respiratory disorders 660 26 Nursing management: upper respiratory tract Interstitial lung diseases 663 problems 597 Valerie Bender Howard (US); Jane Clarke (ANZ) Structural and traumatic disorders of the nose 597 Vascular lung disorders 663 Pulmonary hypertension 666 Inflammation and infection of the nose and paranasal sinuses 599 28 Nursing management: obstructive pulmonary diseases 673 Jane Steinman Kaufman (US); Bridie Kent (ANZ) Diseases and disorders of the paranasal sinuses 605 Problems related to the pharynx 605 SECTION SIX Problems of oxygenation: transport Maryanne Hargraves 29 Nursing assessment: haematological system 730 Problems related to the trachea and larynx 607 Brenda K Shelton, Sandra Irene Rome, Sharon L Lewis (US); Maryanne Hargraves (ANZ)
    • CONTENTS ix30 Nursing management: haematological problems 751 Sandra Irene Rome (US); Maryanne Hargraves (ANZ) Anaemia caused by decreased erythrocyte production 755 33 Nursing management: coronary artery disease and acute coronary syndrome 854 Linda Griego Martinez, Linda Bucher (US); Robyn Gallagher (ANZ) Coronary artery disease 854 Anaemia caused by blood loss 761 Acute coronary syndrome 874 Anaemia caused by increased erythrocyte destruction 762 Sudden cardiac death 890 34 Nursing management: heart failure 894 Problems of haemostasis 768 Mary Ann House-Fancher, Hatice Y Foell (US); Linda Soars (ANZ) 35 Nursing management: ECG monitoring and arrhythmias 914 Linda Bucher (US); Robyn Gallagher (ANZ) 36 Nursing management: inflammatory and structural Lymphomas 790 heart disorders 939 Nancy Kupper, De Ann Mitchell (US); Robyn Gallagher (ANZ) Inflammatory disorders of the heart 939SECTION SEVENProblems of oxygenation: perfusionRobyn Gallagher Valvular heart disease 95231 Nursing assessment: cardiovascular system 808 Angela J DiSabatino, Linda Bucher (US); Linda Soars (ANZ) Cardiomyopathy 95932 Nursing management: hypertension 831 Elisabeth G Bradley (US); Robyn Gallagher (ANZ)
    • x CONTENTS 41 Nursing management: upper gastrointestinal problems 1073 Margaret McLean Heitkemper (US); Ann Framp (ANZ)37 Nursing management: vascular disorders 967 Deidre D Wipke-Tevis, Kathleen Rich (US); Linda Soars (ANZ) Oesophageal disorders 1081 Peripheral arterial disease 967 Disorders of the aorta 968 Disorders of the stomach and upper small intestine 1091 Disorders of the veins 983 42 Nursing management: lower gastrointestinal problems 1121 Marilee Schmelzer (US); Stephanie Buckton (ANZ)SECTION EIGHTProblems of ingestion, digestion, absorption andeliminationAnn Framp38 Nursing assessment: gastrointestinal system 998 Anne Croghan (US); Marie Verschoor (ANZ) Chronic abdominal pain 113339 Nursing management: nutritional problems 1023 Peggi Guenter (US); Di Brown (ANZ) Inflammatory disorders 113540 Nursing management: obesity 1052 Jennifer Kretzschmar, Paula Blackwell, Sharon L Lewis (US); Brighid McPherson (ANZ) Malabsorption syndrome 1167
    • CONTENTS xi Anorectal problems 1171 Obstructive uropathies 126243 Nursing management: liver, pancreas and biliary tract problems 1176 Margaret McLean Heitkemper, Anne Croghan, Paula Cox-North (US); Ann Framp (ANZ) Renal trauma 1270 Renal vascular problems 1270 Disorders of the liver 1177 Hereditary renal diseases 1270 Renal involvement in metabolic and connective tissue diseases 1272 Urinary tract tumours 1272 Disorders of the pancreas 1207 Disorders of the biliary tract 1217 Surgery of the urinary tract 1284SECTION NINEProblems of urinary functionAnn Bonner 46 Nursing management: acute kidney injury and44 Nursing assessment: urinary system 1226 chronic kidney disease 1292 Vicki Y Johnson (US); Ann Bonner (ANZ) Carol M Headley (US); Ann Bonner (ANZ)45 Nursing management: renal and urological problems 1249 Vicki Y Johnson (US); Ann Bonner (ANZ) Dialysis 1313 Infectious and inflammatory disorders of urinary system 1249 SECTION TEN Problems related to regulatory and reproductive mechanisms Jenny Sando 47 Nursing assessment: endocrine system 1336 Immunological disorders of the kidney 1259 JoAnne Konick-McMahan (US); Valerie Cheetham (ANZ)
    • xii CONTENTS 48 Nursing management: diabetes mellitus 1357 Nancy C Robbins, Cory A Shaw, Sharon L Lewis (US); Bronwyn Davis (ANZ) Diabetes mellitus 1357 Disorders of the adrenal medulla 1428 50 Nursing assessment: reproductive system 1431 Shannon Ruff Dirksen (US); Julie Parry (ANZ) Acute complications of diabetes mellitus 1381 51 Nursing management: breast disorders 1453 Cynthia Matthews (US); Marion Strong (ANZ) Benign breast disorders 1456 Chronic complications of diabetes mellitus 1386 49 Nursing management: endocrine problems 1396 JoAnne Konick-McMahan (US); Valerie Cheetham (ANZ) Disorders of the anterior pituitary gland 1396 52 Nursing management: sexually transmitted infections 1479 Shari Goldberg (US); John Rolley (ANZ) Bacterial infections 1480 Disorders associated with antidiuretic hormone secretion 1400 Chlamydia Viral infections 1487 53 Nursing management: female reproductive Disorders of the thyroid gland 1403 problems 1496 Nancy J MacMullen, Laura Dulski (US); Julie Parry (ANZ) Problems related to menstruation 1500 Disorders of the parathyroid glands 1416 Disorders of the adrenal cortex 1419
    • CONTENTS xiii 56 Nursing management: acute intracranial Conditions of the vulva, vagina and cervix 1508 problems 1588 Linda Laskowski-Jones (US); Jacqueline Baker (ANZ) Benign tumours of the female reproductive system 1512 Cancers of the female reproductive system 1514 Inflammatory conditions of the brain 1615 57 Nursing management: the patient with a stroke 1622 Julie T Sanford (US); Sonia Matiuk (ANZ) Problems with pelvic support 1522 58 Nursing management: chronic neurological problems 1646 Sherry Garrett Hendrickson, Stephanie A Elms, Virginia Shaw (US); Jacqueline Baker (ANZ) Headache 164654 Nursing management: male reproductive problems 1530 Shannon Ruff Dirksen (US); John Rolley (ANZ) Problems of the prostate gland 1530 Chronic neurological disorders 1652 Problems of the penis 1546 Problems of the scrotum and testes 1548 Other neurological disorders 1674 59 Nursing management: delirium, dementia and Alzheimer’s disease 1678 Sexual functioning 1550 Virginia Shaw, Sharon L Lewis (US); Wendy Moyle (ANZ)SECTION ELEVENProblems related to movement and coordination 60 Nursing management: peripheral nerve andJacqueline Baker spinal cord problems 169855 Nursing assessment: nervous system 1560 Linda Laskowski-Jones (US); Anna Brown (ANZ) Sherry Garrett Hendrickson (US); Cranial nerve disorders 1698 Jacqueline Baker (ANZ)
    • xiv CONTENTS 63 Nursing management: musculoskeletal problems 1789 Polyneuropathies 1703 Colleen R Walsh (US); Aileen Wyllie (ANZ) Low back pain 1796 Spinal cord problems 1707 Neck pain 1805 Foot disorders 1805 Metabolic bone diseases 1807 61 Nursing assessment: musculoskeletal system 1734 Dottie Roberts (US); Aileen Wyllie (ANZ) 64 Nursing management: arthritis and connective tissue diseases 1815 Dottie Roberts (US); Di Brown (ANZ) 62 Nursing management: musculoskeletal trauma and Arthritis 1815 orthopaedic surgery 1749 Sharon G Childs (US); Aileen Wyllie (ANZ) Soft-tissue injuries 1749 Spondyloarthropathies 1834 Fractures 1755 Complications of fractures 1769 Soft-tissue rheumatic syndromes 1850 Types of fractures 1772 SECTION TWELVE Nursing care in specialised settings Thomas Buckley and Christopher Gordon 65 Nursing management: critical care environment 1858 Linda Bucher, Maureen A Seckel (US); Common joint surgical procedures 1782 Thomas Buckley (ANZ)
    • CONTENTS xv Environmental emergencies 195866 Nursing management: shock and multiple organ dysfunction syndrome 1898 Kathleen M Geib (US); Margherita Murgo (ANZ) 69 Chronic illness and complex care 1979 Linda Soars, Robyn Gallagher (ANZ)67 Nursing management: respiratory failure and acute respiratory distress syndrome 1926 Richard B Arbour (US); Christopher Gordon (ANZ) APPENDICES A Cardiopulmonary resuscitation and basic life support 1995 B Nursing diagnoses 200168 Nursing management: emergency care C Answer key to review questions 2003 situations 1950 Picture credits 2005 Linda Bucher (US); Elizabeth Leonard (ANZ) Index 0000
    • Chapter 68 NURSING MANAGEMENT: emergency care situations Written by Linda Bucher Adapted by Elizabeth Leonard LEARNING OBJECTIVES KEY TERMS 1 Understand the principles of patient assessment in the emergency department, chemical, biological and radiation (CBR) including triage, primary survey and secondary survey. hazards, p 1974 2 Differentiate between the various types and victims of violence: accidental versus children at risk, p 1956 abuse (domestic violence and children at risk). disaster, p 1972 3 Recognise the significance of ‘mechanism of injury’ and initial signs and symptoms domestic violence, p 1956 for identifying actual or potential traumatic injury. emergency, p 1972 4 Describe the pathophysiology, assessment and multidisciplinary care of select envenomation, p 1965 environmental emergencies, including hyperthermia, hypothermia and submersion frostbite, p 1962 injury. heat cramps, p 1959 heat exhaustion, p 1960 5 Identify a selection of Australia’s venomous creatures and discuss the principles of heat stroke, p 1961 management for envenomation. hyperthermia, p 1959 6 Explain the principles of care for select toxicology emergencies. hypothermia, p 1961 7 Explore the strategies of preparedness for the management of major incidents, jaw-thrust or chin-lift manoeuvre, p 1953 emergency and/or disaster. major incident, p 1972 8 Describe the toxic agents and the principles of management for chemical, biological mechanism of injury, p 1956 and radiation hazards. primary survey, p 1951 rapid-sequence induction, p 1953 secondary survey, p 1954 submersion injury, p 1963 toxicology, p 1969 triage, p 1950 Cost and access Population and social change Assessment of the emergency patient triage 1950
    • 1972 SECTION 12 Nursing care in specialised settings Haemodialysis and haemoperfusion Antidote administration Civil Defence Emergency Management Act 2002 emergency disaster Community Welfare Act 1987 PSYCHOLOGICAL SUPPORT Major incident and disaster preparedness major incident
    • CHAPTER 68 NURSING MANAGEMENT: emergency care situations 1973 EMERGENCY SERVICESFigure 68-8 Transferring an injured person to hospital.Source: Photolibrary.Figure 68-9 Severe crush injuries may result from the damagecaused by an earthquake, such as the recent Christchurchearthquake.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 Figure 68-11 Patient injuries from the Bali terrorist attack. Note Figure 68-12 Penetrating wounds received as a result of a triage assessment. bomb blast. Source: Used with permission. Royal Darwin Hospital, Clinical Photo Library. Source: Used with permission. Royal Darwin Hospital, Clinical Photo Library. Chemical, biological and radiation hazards Chemical, biological and radiation (CBR) hazards Figure 68-13 Chest X-ray showing ball-bearing bomb injury. Source: Used with permission. Royal Darwin Hospital, Clinical Photo Library. TABLE 68-10 Chemical agents of terrorism by target organ or effect Nerve Blood Pulmonary Blister/vesicants Sarin (isopropyl methylphosphonofluoridate) Hydrogen cyanide Phosgene Nitrogen and sulfur mustards Tabun (ethyl N,N-dimethylphosphoramido- Cyanogen chloride Chlorine Lewisite (an aliphatic arsenic cyanidate) Vinyl chloride compound, 2-chlorovinyl- Soman (pinacolyl methylphosphonofluoridate) dichloroarsine) GF (cyclohexyl methylphosphonofluoridate) Phosgene oxime VX (O-ethyl S-[2-diisopropylaminoethyl] methylphosphonothiolate)
    • TABLE 68-11 Terrorism with ionising radiation: general guidance pocket guide Whole body radiation from external radiation or internal absorption Subclinical range Sublethal range Lethal rangePhase of syndrome Feature 0–100 RAD 100–200 RAD 200–600 RAD 600–800 RAD 800–3000 RAD >3000 RADInitial or prodromal Nausea, vomiting None 5–50% 50–100% 75–100% 90–100% 100% Time of onset Unaffected 3–6 h 2–4 h 1–2 h <1 h Minutes Duration No impairment <24 h <24 h <48 h <48 h N/A Lymphocyte count ( 109/L) Minimally <1000 at 24 h <500 at 24 h Decreases within Decreases within CNS function decreased Routine task Simple and hours hours No impairment performance; routine task Progressive Progressive cognitive performance; incapacitation incapacitation impairment for cognitive occurs occurs 6–20 h impairment for >24 h‘Manifest illness’ (obvious Signs and symptoms None Moderate Severe Severe Diarrhoea Convulsions, illness) leucopenia leucopenia, leucopenia, Fever ataxia, tremor, purpura, purpura, Electrolyte lethargy CHAPTER 68 haemorrhage haemorrhage disturbance Pneumonia Hair loss after 300 rad Time of onset >2 weeks 2 days–2 weeks 2 days–2 weeks 1–3 days 1–3 days Critical period None None 4–6 weeks 4–6 weeks 2–14 days 1–48 h Organ system Haematopoietic Haematopoietic GI tract CNS and respiratory and respiratory Mucosal systems (mucosal) (mucosal) systems systemsHospitalisation 0% <5% 90% 100% 100% 100%Mortality 0% 0% 0–80% 90–100% 90–100% 90–100%Time to death 3 weeks– 3 weeks– 1–2 weeks 1–2 days 3 months 3 monthsCNS, central nervous system; GI, gastrointestinal; N/A, not applicable.Source: Armed Forces Radiobiology Research Institute (AFRRI). Pocket guide: emergency radiation medicine response, September 2008. Available at www.afrri.usuhs.mil/outreach/pdf/AFRRI-Pocket-Guide.pdf. NURSING MANAGEMENT: emergency care situations 1975
    • 1976 SECTION 12 Nursing care in specialised settings CASE STUDY The trauma patient Patient profile Asymmetrical chest movement A 20-year-old female trauma patient is brought to the emergency Vital signs: blood pressure 90/40 mmHg, heart rate 130 beats/min, department in an ambulance. She was the driver in a motor vehicle respiratory rate 36 breaths/min collision and was not wearing a seat belt. Two children in the car were O2 saturation 82% pronounced dead at the scene. The paramedics stated that there was significant damage to the car on the driver’s side. CRITICAL THINKING QUESTIONS 1. What life-threatening injury does this patient probably have? Subjective data 2. What is the priority of care? Patient asks, ‘What happened? Where are the children?’ 3. What interventions are needed immediately? Complains of shortness of breath and abdominal pain 4. What other interventions should the nurse consider? 5. Several family members have arrived in the emergency Objective data department, including a woman who states her child was in the Physical examination car (one of the children who died). The second child who died was 4 cm head laceration the patient’s child. How should the nurse approach the family? Badly deformed right lower leg with a pedal pulse by Doppler only 6. Based on assessment data presented, write one or more nursing Glasgow Coma Scale score = 14, unequal pupils diagnoses. Are there any collaborative problems? Decreased breath sounds on left side of chest Review questions 6. A chemical spill has occurred in a nearby industrial site. The first responders report that approximately 1. An elderly man arrives at the emergency department. He is 20 victims need to be transported to the emergency tachypnoeic and disoriented, and his skin is hot and dry. department after decontamination at the site. This is The priority for treatment at this point is to: an example of: A assess his airway, breathing and circulation A a major incident B obtain a detailed medical history from his family B a natural disaster C obtain a urine specimen for urinalysis C a disaster D start oxygen administration and medical assessment D an emergency 2. A patient has presented with a core temperature of 32.2°C. 7. Which of the following biological agents has no effective The most appropriate rewarming technique would be: treatment? A passive rewarming with body-to-body contact A anthrax B active core rewarming using warmed intravenous fluids B botulism C passive rewarming using air-filled warming blankets C smallpox D active external rewarming by submersing in a warm D Ebola virus bath 3. The recommended management for reducing the absorption of many ingested poisons is: References A ipecac syrup B milk dilution C gastric lavage D 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 circulation B ice pack to the bite site to reduce pain and decrease circulation to the bite area, immobilising the venom C direct pressure over the bite site and a firm crepe bandage over the site then up the entire limb D 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 m B motor cyclist in a collision with a car at 40 km/h C burns to 10% body surface area D pedestrian killed by a car
    • Chapter 69Chronic illness and complex careWritten by Linda Soars and Robyn GallagherLEARNING OBJECTIVES KEY TERMS 1 Describe the major causes of chronic illnesses. care coordination, p 1986 2 Explain the characteristics of a chronic illness across the life span. care navigation, p 1985 3 Explore complex illnesses and the assessment of comorbidities in adults. case management, p 1989 4 Describe self-management and self-care principles relating to chronic illness chronic illnesses, p 1979 management. disease management, p 1982 exacerbation, p 1979 5 Evaluate the models of care used to manage chronic and complex illnesses. self-efficacy, p 1985 6 Identify the workforce requirements for health workers in meeting needs for chronic self-management, p 1982 illness management. social cognitive theory, p 1982Chronic illnessChronic illnesses ā The complexity of chronic illness exacerbation 1979
    • 1980 SECTION 12 Nursing care in specialised settings Health Acute Onset Comeback Stable Stable Downward Crisis Stable k ebac Com Stable Dy gin Illness Months TIME 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). ā TABLE 69-1 Chronic illness trajectory Phase Description ā Onset Signs and symptoms are present Disease 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 management Comeback Gradual return to an acceptable way of life Crisis Life-threatening situation occurs Emergency services are necessary Unstable Unable to keep symptoms/disease course under control Life becomes disrupted while working to regain stability Hospitalisation not required Downward Gradual and progressive deterioration in physical/mental status Accompanied by increasing disability and symptoms Continuous alterations in everyday life activities Dying 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. ā
    • CHAPTER 69 Chronic illness and complex care 1981 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 inPatient and family assessment heart failure. J Cardiovasc Nurs 2011; 2. Management of chronic illness MODELS OF CHRONIC ILLNESS CARE self-management
    • 1982 SECTION 12 Nursing care in specialised settings TABLE 69-2 Models of care Service type Model Rationale for use Emergency department Fast-track for lower triage categories A large number of models have been tried around the Admission using 3-2-1 time limit world to improve the flow of people with an Clinician initiative nurses (CINs) unplanned health crisis through the emergency Nurse practitioners system. A triage process is used in all emergency Aged care services in emergency team departments to ensure care by need, but there is also Nurse protocols benefit in treating and discharging people with Emergency medical unit problems that can be managed in the community via Psychiatric emergency care centre alternative care pathways. Inpatient services Chest pain Once admitted, patients receive targeted assessments, Clinical decision reviews and interventions designed to be given within Short stay a time-limited period. They are discharged earlier and Assessment unit: medical/aged care/surgical receive appropriate ongoing care at home. Hospital-in-the-home services Acute short-term medical, nursing and allied Patients receive care in their own homes that would health services. usually be delivered in a hospital setting. Slow stream rehabilitation services—transitional care support. Community-based services Chronic disease rehabilitation Offered to individuals and groups to support, educate Self-management programs and rehabilitate people experiencing exacerbations of Short-term support services offering 2–3 services their chronic illness. (e.g. NSW Compacks) BOX 69-2 Avoiding hospital admissions: what does the evidence tell us? Interventions with evidence of a positive effect Reducing admissions PRINCIPLES OF SELF-MANAGEMENT Continuity of care with a general practitioner Hospital at home as an alternative to admission Assertive case management in mental health Self-management Self-management Early senior review in the emergency department Multidisciplinary interventions and telemonitoring in heart failure disease management Integration of primary and secondary care Reducing readmissions Structured discharge planning Personalised healthcare programs Interventions with evidence of little or no beneficial effect Pharmacist home-based medication review Intermediate care Community-based case management (generic conditions) Early discharge to hospital at home on readmissions Nurse-led interventions pre- and post-discharge for patients with chronic obstructive pulmonary disease Interventions for which further evidence is needed Increasing the size of general practice surgeries Changing out-of-hours primary care arrangements Chronic care management in primary care Telemedicine Cost-effectiveness of general practitioners in the emergency department Access to social care in the emergency department Hospital-based case management Rehabilitation programs Rapid response teams Source: Purdy S. Avoiding hospital admissions: what does the research social cognitive theory 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 1983TABLE 69-3 A systematic review of disease management interventions for patients with chronic heart failureIntervention Approach EvidenceMultidisciplinary interventions A holistic approach bridging the gap Overall concept embedded in multidisciplinary teams— between hospital admission and supports an interprofessional, collaborative approach to discharge, delivered by a team health service provision.Case management interventions Intense monitoring of patients Case management in the community and in hospital is not following discharge, often involving effective in reducing generic admissions. There is limited telephone follow-up and home visits 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 Specialised clinics or mini-clinics (where a group delegates a with chronic diseases for that clinic 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 publicconsultation on an Information Revolution. London: King’s Fund; 2010. Maintaining a ‘normal’ lifeREQUIREMENTS FOR SELF-MANAGEMENTDealing with chronic illness Dealing with emotions
    • 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 Education about heart failure General self-management of symptoms Symptom monitoring practitioner, clinical Refer to cardiologist for nurse specialist and assessment for cardiac heart & lung health rehabilitation team Flexible diuretic regimen Management of fluid retention To encourage self-monitoring Education about Dietician, clinical of increased fluid retention daily weights nurse specialist and decreased sodium intake heart & lung health fluid restriction team Modification of activities of To encourage independence in Occupational therapy Occupational daily living (ADLs) ADLs assessment therapist and Community nursing assessment community nurse Medication management To understand and comply with Community pharmacist or General medication regimen specialist nurse assessment practitioner and pharmacist Psychosocial support To manage anxiety and avoid Counselling Social worker and significant depression Refer to positive living group group coordinator Increase physical activity To gradually increase activity Education about daily graded Exercise tolerance exercise physiologist, Refer to CCF/COPD group clinical nurse specialist and heart & lung health team Patient health goals and Patient to provide health goals Discuss and write patient’s goals Exercise motivation in own words to allow measurement over time 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 1985SELF-EFFICACY IN SELF-MANAGEMENT self-efficacy care navigatorsENCOURAGING SELF-MANAGEMENT CARE NAVIGATION Care navigation
    • 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 Appointment needs Management goals Action required Provider date Discuss patient self- To define the patient’s goals Discuss current health plan Diabetes nurse or management goals for Write patient’s health goals general diabetes practitioner Assess patient’s confidence To observe the patient’s skill set Assist to set test frequency and Diabetes nurse or and skills to manage for diabetes management tasks ranges for blood sugar level general diabetes practitioner Assess patient’s lifestyle To set goals to manage Discuss plan and timeframe to Diabetes nurse or risks (SNAPW: smoking, identified risks manage each risk identified general nutrition, alcohol intake, practitioner physical activity, weight) Assess patient’s coping To measure anxiety and Discuss treatment plans Psychologist/ skills—emotional impact depression levels Access psychological services counsellor and social support Prepare multidisciplinary To define the needs for allied Refer to allied health workers to General team care plan as needed health services to support the collaborate with the care plan practitioner plan 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 69-3 Sample self-management care plan for blood sugar levels. CARE COORDINATION Care coordination
    • CHAPTER 69 Chronic illness and complex care 1987 Care navigation—guided to the right point of care Community-based rehab and education Acute hospital services Seek out alternative pathways to hospital admission Chronic disease self-care Chronic disease team Family and High-risk Clinical knowledge carers patient with Emergency department General chronic and practitioner complex disease Assertive discharge Social and personal planning for support hospital-in-the-home Threshold modelling services services, transitional care servicesFigure 69-4 The care navigation process. Predictive modelling Transitions and care coordination in chronic illness care Community Health systems Resources and policies Organisation of healthcare Delivery Decision Clinical Self- system support information management design systems support Informed, Productive Prepared, active interactions proactive patient practice team Improved outcomesFigure 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 Part B: factors impacting on self-management 1. Presenting clinical symptoms 5. Psychosocial factors and demographic issues Diagnosis of chronic respiratory condition (1) Mental health (depression, anxiety or psychiatric problems) Y/N Diagnosis of chronic cardiac condition (1) Disability (intellectual, physical, visual, hearing) Y/N Diagnosis of complex care needs in frail aged, such as dementia, falls Access to suitable transport to care services Y/N or incontinence (1) Financial issues (inability to afford health services and/or Diagnosis of complex care needs in people less than 55 years of age, medications) Y/N such as mental health illness (1) CALD or Aboriginal health beliefs Y/N Comorbid diagnosis of diabetes and/or renal failure and/or liver Illiterate and/or limited English Y/N disease (1) Unstable living environment Y/N Score: /5 Socially isolated Y/N Drug and alcohol problems Y/N 2. Service access profile Rate the impact these combined factors have on the person’s ability Acute admission/presentation (more than once in the last 12 to self-manage their condition: months) (4) No impact (on ability to self-manage) (0) No regular GP follow up (regular medical check-ups 2 times a year) Low impact (on ability to self-manage) (7) (3) High impact (on ability to self-manage) (15) Reduced ability to self-care (to the extent it impacts on disease Score /15 management) (3) Score: /10 6. Readiness to change assessment (choose one only) No capacity for self-management (cognitive impairment, end-stage 3. Risk factors disease) (4) Smoking (1) Pre-contemplation (not ready for change) (3) Overweight (guide BMI 26–35) (1) Contemplation (considering but unlikely to change soon) (3) Underweight (guide BMI <19) (1) Preparation (intending to take action in the immediate future) (2) High cholesterol (total cholesterol >5.5 mmol/L, HDL <1.0 mmol/L, Action (actively changing health behaviours but having difficulties LDL >2.0 mmol/L) (1) maintaining plan) (1) High blood pressure (>140/90 mmHg or on medication for high Maintenance (maintained behaviour for >6 months) (1) blood pressure) (1) Relapse (a return to the old behaviour) (3) Physical inactivity (less than 30 mins/day and 4 days/week) (1) Score: /4 Polypharmacy (>5 medications with difficulty managing them) (1) Score: /7 Total score for self-management impact (B) /19 Overall risk: add part A and part B /49 4. Extenuating factors Use of services previously (1) The higher the score, the higher the risk of readmission. 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 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 CASE STUDY The patient with chronic illness Patient background Mrs 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 dataConclusion Temperature: 36.8 C Heart rate: 116 beats per min Blood pressure: 92/60 mmHg Cardiac rhythm: atrial fibrillation Cardiac system: S1 and S2 present, no murmurs Respirations: 32 shallow Lung sounds: crackles in both bases Daily 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? Review questions1. Vos and Carter found that a large impact on improving a 4. Depression frequently accompanies or may precipitate population’s health can be achieved by: chronic illness. Depression makes recovery and A taxation of tobacco, alcohol and unhealthy foods management more difficult because it can make it harder B mandatory limits on salt added during production of for people: three basic food items (bread, cereals and margarine) A to find the energy to eat healthily C gastric banding for severe obesity B to exercise or take medication regularly D all of the above C as it can reduce initiative and affect adherence and2. Many factors contribute to chronic disease complexity and compliance with health action plans these are characterised by: D all of the above A periods of exacerbation 5. Measuring carer strain and completing social care B the chronic illness and its treatments generating assessments are an important part of assessing the impact further issues of these factors for different phases of the chronic illness C the individual with chronic illness experiencing journey. This is because: unequal access to care and support A carers have become too focused on their own needs D all of the above and have neglected those of the patients under3. Australian and New Zealand evidence suggests that most assessment of the recent gain in life expectancy for individuals: B there are so many government programs for patient A is a result of better preschool education and social support that a different assessment has to be preparation-for-life classes completed for each one B is spent accompanied by disability in the final years, C a review of the domestic support needs and carer and that much of the extra life years gained are spent factors enables the case manager to effectively plan with a profound or severe core activity limitation interventions that meet the patient’s goals and needs C is needed to expand the taxation base to pay for D all of the above healthcare D is expected by the population due to their higher taxes
    • 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 support B account for the conflicting symptoms and strategies of multiple illnesses C 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 above 7. 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 health C 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 disorder B heart failure in a patient with untreated hypertension C a change in sputum colour to yellow/green in a person with emphysema D 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 wrong B measuring daily weights to detect fluid overload for people with heart failure C not measuring the blood sugar level when feeling well D all of the above References
    • CHAPTER 69 Chronic illness and complex care 1993 ResourcesAustralian Disease Management AssociationAustralian Institute of Health & WelfareAustralian Resource Centre for Hospital InnovationsAustralian Vascular Biology SocietyCardiac Society of Australia and New ZealandCardiomyopathy Association of AustraliaCase Management Society of AustraliaChronic Care for Aboriginal People ProgramDiabetes AustraliaDiabetes New ZealandHeart Support AustraliaInternational Disease Management AllianceJuvenile Diabetes Research FoundationMāori HealthNational Heart Foundation of AustraliaNational Heart Foundation of New ZealandNew Zealand Guidelines GroupNew Zealand Ministry of Health