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Nur258 Resources

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    Nur258 Resources Nur258 Resources Document Transcript

    • NUR258 Resources The following resources comprised part of the module handbook for NUR220 in the Competency Curriculum. They are reproduced here with thanks for the work done by the developers of that module. Please remember that the work was devised several years ago now, so needs to be used with a certain amount of caution to take account of recent changes in therapy and evidence. NUR261 ‘Health Policy and Health Promotion’ will cover issues related to health promotion and epidemiology, so reading here will be a good preparation for that module.
    • Guided Study: The Patient with a Respiratory Problem Today you will be researching information about the care of patients with chronic respiratory problems. Below you will find a scenario about an individual with chronic obstructive pulmonary disease; a term which describes several conditions in which the end result is hypoxia. The second set of activities relate to a young woman who is admitted to hospital with an acute attack of asthma and hypoxia. Work through the list of activities and be prepared to discuss some of your researched information to the class in the time-tabled session. You will have the opportunity to demonstrate your understanding of both conditions by completing a short quiz at the end of the activities. John James Mr James, aged 58, retired from his job in the naval dockyard three years ago on health grounds because of chronic obstructive pulmonary disease (COPD). He is a heavy smoker and has tried a number of times to give up. He is admitted to the medical ward with an acute exacerbation of his condition. On admission he is pyrexial (T.38C), breathless with a productive cough, tired but agitated. Activity 1 Explain the term chronic obstructive pulmonary disease and describe the possible causes. Activity 2 Using an A&P textbook, revise the normal physiology of respiration and explain the abnormal physiology in COPD Activity 3 On the assessment sheet provided, insert the subjective and objective assessment data you would expect to gather about Mr James. Subjective data is what the patient and others tell you and objective data are the physical signs that you detect from your clinical observations.
    • Activity 4 Mr James is prescribed 28% oxygen via a Venturi mask. Explain how the respiratory drive is altered in patients with COPD and why a higher level of oxygen administration could be life threatening. With reference to Mallett and Bailey (2000) list other hazards of oxygen therapy, and the safety measures which should be taken by staff, patients or carers. Activity 5 Using the attached assessment/care plan sheet, devise a plan of care for Mr James and also state how you would evaluate whether the plan is meeting his needs. Activity 6 What advice will you give him on his discharge home to help him avoid future exacerbations? Mary Smith This morning Mary, aged 19, went for a session on the dry ski slopes with her university friends. Following her third down hill run she became increasingly breathless. Mary has had Asthma since the age of four, and for several years has only used her salbutamol metered dose inhaler prior to strenuous exercise. She uses her salbutamol inhaler now but this does not relieve her breathlessness. As she is distressed and frightened her friends call an ambulance. The ambulance takes Mary to the Accident & Emergency Department where a diagnosis of an acute severe attack of asthma is made Activity 1 Explain the possible causes of asthma.
    • Activity 2 Describe the abnormal physiology related to Mary’s acute asthma attack with special reference to her current problems of expiratory laboured breathing, production and retention of sputum and her distress. Most Hospital Trusts have devised patient group directions for the emergency treatment of asthma to enable speedy treatment as it can be exhausting and life threatening. Emergency treatment with assisted ventilation and admission to an Intensive Care Unit may be required. However Mary’s reduced peak flow recordings, her tachycardia of 115, respiratory rate of 28 and inability to complete a sentence in one breath indicated that her attack is an acute severe attack, rather than life threatening at present. She is prescribed high flow oxygen, Salbutamol via the nebuliser driven by oxygen four hourly and oral Prednisolone 30 mg. daily. She also has an intravenous infusion sited. Activity 3 Explain the actions of Salbutamol and Prednisolone, stating their possible unwanted effects. Mary is transferred to the ward where her condition rapidly improves enabling her to resume her metered aerosol of Salbutamol. Activity 4 You are asked to assist Mary with her inhalation technique to ensure it is effective. Describe the correct use of an inhaler. Activity 5
    • Discuss appropriate approach and content of patient education for Mary prior to her discharge from hospital. BTS Guidelines recommend that no patient should leave hospital without a written asthma action plan. Suggested Reading BMA (1997)The New Guide to Medicines & Drugs Goldalming. The Colour Library Direct Dunn L.(1998) Oxygen therapy. Nursing Standard. Vol.13. No.7. 57-60, 63-64. Edmund C (2000) The Respiratory System. in Alexander M. Fawcett J. & Runciman P Nursing Practice Hospital & Home. The Adult 2nd Ed. Edinburgh. Churchill Livingstone Long, Phipps & Cassmeyer (1995) Adult Nursing: A Nursing Process Approach London. Mosby Mallet. J. & Dougherty (Ed) (2000) Manual of Clinical Nursing 5th Ed. London: Blackwell Science Prosser,S. et al (2000) Applied Pharmacology London. Mosby Roberts J.(2002) The management of poorly controlled asthma. Nursing Standard. Vol.16. No.21. p45-53. http://www.asthma.org.uk http://www.brit-thoracic.org.uk/guide/guidelines.htlm (Revised 2003) Quiz – Respiratory Disease Word Search
    • Crack the clues and find the words This drug may kill life to save life A disease characterised by inflammation and bronchospasm Acute or chronic. Is usually associated with upper respiratory tract infection or atmospheric pollution A plan of care Cell which respond to chemicals, such as O2 or CO2 bound to receptors on their membranes. The medulla oblongata acts as a centre for this reflex Difficulty in breathing When activated releases histamine and leukotrienes. An aid to converting liquid into an aerosol mist 21% of dry air, but only 16% of expired air. A 2 adrenoreceptor stimulant often given by inhalation Increased in Inflammation, often colourful in infection. Prepared by C Wheeler and M Gillard (1998), updated by C Wheeler (2001) and D Kerslake (2002)
    • R O T P E C E R O M E H C L L E C T S A M B O N A E O C A R B O N T R I C E P M Z R F R E T A N I B O R A H G U O C I C T F N N I T N X V N O M O E U E P M U E L A C K I M N R B S I B G A V H B N U S R U Y D L Y M S I A Y T I U L D E A X I T T C X U O L I D F S O N N I H I P N E S I J K A A I S O M S I S E O G S N A L P E R A C U R V E
    • Assessment using Activities of Living Model (Roper, Logan and Tierney 1996) Activity of living Assessment Data Plan of care Maintaining a safe environment Breathing Communicating Eating & drinking Elimination Personal cleansing & dressing Controlling body temperature Mobilising Working & playing Expressing sexuality Sleeping Dying Guided Study: Epidemiology Work Book
    • Aim In Module 116 of the common foundation programme you received a brief introduction to the science of epidemiology. The aims of this work book are to refresh your knowledge and further develop your understanding of epidemiology within the context of public health. Objectives 1. To define epidemiology 2. To identify methods of data collection 3. To critically review public health data in relation to local health
    • Definition Epidemiology is the study of how often diseases occur in different groups of people and why. It is used to plan and evaluate strategies to prevent illness and in addition it can be a guide to managing patients currently with disease. It is particularly beneficial in Public Health work for identifying disease patterns and therefore subsequent management. Epidemiology is a term derived from Greek language EPI - upon DEMOS - people LOGOS - Science It is the science of health events in Human Populations, the study of how health states are distributed in the population and what environmental conditions, lifestyles or other circumstances are associated with the presence or absence of disease. It is concerned with the who, what where, when and how of disease causation (Valanis,1986). To understand epidemiology you must first refresh yourselves on the causal relationships in the disease process. Agent:- a factor whose presence causes a disease or one whose absence causes disease. Environment:- refers to the external conditions and influences affecting the life of living things, i.e. the physical, biological and socio-economic conditions where agents reside and reproduce. Host:-
    • is the individual human in whom an agent produces disease. Disease can occur only in a host who is susceptible. In some conditions there are direct causal association. E.g. the tubercle bacillus will cause tuberculosis, whereas an example of indirect causal association is when a person smokes cigarettes causing damage to the respiratory epithelium which in turn makes the individual more susceptible to infection which in turn may lead to the condition of chronic bronchitis. By identification of pathogenic agents and environmental influences, epidemiological research into aetiology seeks to prevent their interaction with human agents (Barker, rose, 1990). Aetiological studies represent a major use of epidemiological methods, studies produce information on the natural history of the disease. Natural history refers to the processes leading to disease occurrence, before any intervention and to the course and outcome of the disease process. Epidemiology is the measurement of disease outcomes in relation to a ‘population at risk’. Population at risk = group of people whether they be healthy or sick who would be counted as a case if they had the disease / condition being studied. E.g. If a Practice Nurse was measuring the number of mothers who might seek information about childhood vaccinations (they may not necessarily want their child to be vaccinated). They could only be included in the population at risk if they are registered with the Practice the nurse worked for. Epidemiological conclusions (on risk) cannot be drawn purely from the number of sick people seen. Implicit in any epidemiological investigation is the notion of a target population about which conclusions are drawn. Occasionally a study can be undertaken on the whole target population e.g. currently any new case of Jacob Creutzfeldt disease is being closely monitored and studied. However, it is more common to study a sample of the target population – study sample. Target population -> study population ->study sample
    • From the target population an accessible subset is determined which is known as the study population and from this subset a study sample is subsequently often taken for study. A study population begins with some characteristic, which all its members have in common. This may be geographical, (e.g. all people living in a given area), or it may be occupational (e.g. all coal miners), or possibly diagnostic (e.g. all people with a given condition). Age, sex, or both may further break down this population. Epidemiology primarily relates to groups rather than individuals. In other words it provides nomothetic rather than idiographic information or data. Conclusions from epidemiological studies are based on comparisons of data. Clues to the causes of disease come from comparing disease rates in groups with differing levels of exposure e.g. in Camelford epidemiologists studied the effect of the pollutant in the water supply of those people exposed as compared to those people who were not exposed. Epidemiology is dependent on heterogeneity. If all people smoked 20 cigarettes a day it would be impossible to compare the effects of smoking 20 cigarettes a day on the incidence of lung cancer (i.e. no control group for comparison). By comparing data it is possible to identify high risk and priority groups within a community (population). Another task of epidemiology is to monitor disease and to survey over time disease trends e.g. are they increasing, decreasing or changing in their distribution and if so why? Epidemiological studies are required to identify any emerging problems (e.g. from BSE) and are able to assess the effectiveness of measures being taken to control the problem. Measuring Disease Frequency in Populations In order to do this, there needs to be some form of diagnostic criteria, however, it must be remembered diseases in populations tend to exist as a continuum of severity rather than an all or nothing phenomena.
    • Several measures of disease frequency are in common use. Incidence – the rate at which new cases occur in a population during a specified period. Incidence is measured as the number of New Cases over the Population at Risk X Time during which Cases were ascertained. For example if 15 people developed lung cancer in 1990 the incidence is 15 per 100,000 per year or per 100,000 person- years. Incidence measures occurrence of disease as a rate, whereas prevalence does not. Changes in population at risk due to births /deaths / migration is overcome by relating number of new cases to the person years at risk. This is calculated by adding together the periods during which each individual member of population at risk during measurement period. i.e. the Number of New Cases over Total Person Years at Risk. Episodes usually relate to first contact except for infectious diseases. Prevalence The proportion of a population that are cases (with the disease) at a point in time. For example the number with lung cancer in a population of 100,000 in December 1990 is 30. Prevalence is therefore 30 over 100,000 or 0.0003. Prevalence considers all sufferers regardless of when they were diagnosed. This measure is only suitable for stable conditions and not suitable for acute disorders. Period Prevalence Proportion of a population that are cases at any time within a stated period. Mortality Incidence of death from disease Interrelation of incidence, prevalence, and mortality
    • Each new incident or case enters a prevalence pool and remains there either until recovery or death. If recovery and death rates are low, then chronicity is high and even a low incidence will produce a high prevalence: - Prevalence = incidence x average duration When studying aetiology, incidence is the most appropriate measure of disease frequency. You need to be aware that patterns of mortality can be misleading if survival is variable e.g. the recent decline in mortality from testicular cancer is a result of improved treatments it does not reflect a fall in the incidence of the disease itself. In the study of rarer conditions e.g. Huntingdon’s Chorea where it is difficult to obtain large numbers prevalence is often used as an alternative to incidence. Crude and Specific Rates A crude incidence, prevalence or mortality rate is one that relates to results for a population taken as a whole, without subdivision or refinement. Crude live birth - no. live births/total mid year population x 1000 Crude death rate - no. of death/total mid year population x1000 A specific rate is where the data has been broken down for specific age / sex. Although incidence and prevalence have been discussed in relation to onset and presence of disease these may be extended to include other factors e.g. unemployment, smokers etc. Other Rates that you may come across include:- General fertility rate - Number of live birth/no of women aged 15-44 x 1000 Infant Mortality Rate - Number of deaths of children aged below 1 year/1000 live births per annum.
    • Still birth rate - Number of intrauterine deaths after 28 weeks/ 1000 total births per annum Perinatal mortality rate - Number of stillbirths and deaths in 1st week of life / 1000 total births per annum Age specific death rate - Number of death of people of specified age/number of people in population of that age. Cause specific death rate - number of deaths from from specific cause/total mid year population x 1000. Comparing Disease Rates As a practitioner in the community from time to time you will probably ask yourself questions e.g. ‘Is this incidence of this disease on the increase?’ ‘Does it occur in the community I work more frequently than other areas?’ ‘Is there a relation between the incidence and a suspected cause?’ In order to answer these questions it is necessary to set two rates side by side and make some sense of the comparison. However you need to be aware of some problems that may arise. The ICD system is the International Classification of Diseases, Injuries and Causes of Death and is published by the World Health Organisation. This system is revised periodically, on occasions the categories change and so disease rates may not be directly comparable! Measures of Association Relative Risk is the measure most often used by epidemiologists. Relative risk is the ratio of the disease rate in exposed persons to that in people who are unexposed. Odds Ratio is the odds of the disease in the exposed person divided by the odds of the disease in unexposed person.
    • A problem with measuring statistics in health is that most epidemiological studies are observational not experimental and will compare groups of people who vary in many ways. Because there is more than one variable it may be difficult to know what is the causes and effect of disease patterns. These differing variables are called confounding variables. Two common confounding factors are age and sex e.g. if you look at the crude mortality rates of two areas in east Devon you may find that Seaton has a much higher mortality rate than Exeter. You cannot assume from this that Seaton is less healthy it may be just that there are more elderly people living there. In order to get over this problem epidemiologists use what is called Standardised or adjusted rates. Direct Standardisation Compares weighted averages of sex and age specific disease rates, the weights being equal to the proportion of people in each age and sex group in a convenient reference population Indirect Standardisation This method is used for large studies. As a community nurse you may visit a large number of school aged children with a staphylococcus infection. You may wonder whether or not this is increasing or comparable to what would be expected. To establish this, you would take a sample of all the school aged children on your list and identify how many had a staphylococcus infection, you would then take the total number of the school age population in a given reference population e.g. all school aged children in the county. You could then multiply the number of children in your study with the symptom prevalence in your reference group this gives you the
    • expected number of cases in a group of that age and size based on the reference population’s rates So therefore if in your population you had seen 4 children with a infection and the expected number was 2.5 this would give a standardised prevalence ration of 4/2.5 = 160%. The Standardised Mortality Ratio (SMR) is widely used by the registrar general in summarising time trends and regional and occupational differences. An SMR is an index of mortality that enables the comparison to be made between populations, allowing for age sex differences. For example the mortality in a local government area can be compared with the region or with England and Wales. It is a ratio of the number of deaths observed in an area, compared to the number of deaths expected given national death rates. An SMR of 100 indicates a similar number of deaths as expected; an SMR of 120 would indicate 20% more and an SMR of 80% would be 20% less. Rates in an area could be skewed by the fact that there are high numbers of a susceptible population in the locality. SMR compensates for the effects of differing age and sex distribution by: 1. Calculating age-specific death rate for whole population nationally. 2. Multiply this by age-specific population for the area, to give number of deaths to be expected if the area follows national pattern. 3. Divide actual deaths in the area, according to cause by expected deaths and express as a percentage. 4. A value significantly higher or lower than 100 indicates that mortality differs from the national trend for reasons other than age/sex. 5. SMR greater than 100 indicates a significant health problem. Two scores that you may be familiar with are the Townsend and Jarman scores. These are derived from national census data and are used to assess relative
    • deprivation in any given area. The average national score is 0 for both indicators with high values above 0 indicating relatively high deprivation. Jarman scores are based on GP workload using the proportion of the prevalence of the following:- children aged under five; ethnic minorities; single parent households; unskilled manual workers; highly mobile people; overcrowding; poor housing and unemployment. Townsend examined and tried to explain trends in health inequalities. His score uses the prevalence or proportion of the following:- economically active residents who are unemployed; car ownership; owner occupied households and overcrowding in private households. More recently the Department of the Environment, Transport and the regions has published the Indices of Deprivation (2000). The information is timelier than other commonly used data which rely on the ten year census. This work sheet has provided you with an introduction to epidemiology and some of the common terminology used.
    • Demography and Epidemiology Quiz 1. What is the approximate resident population of the county in which you live? 2. Name the PCTs in the county. 3. Which PCT has the highest percentage of people over 75 years of age? 4. Why do you think this is the case? 5. What is the index of multiple deprivation (IMD 2000) made up of? 6. What are the problems with this score when measuring health? 7. What are the most common causes of death and premature mortality in the county? 8. Is the all age, all cause SMR for the county higher or lower than expected rates of death? 9. What is the SMR for Skin Cancer? 10. Is this higher or lower than expected? 11. What is the biggest single cause of death in the county? 12. Which areas have the highest SMR? 13. Consider the data for accidents. Comment on variations in death rate and hospital admissions in different parts of the county and age groups. 14. Eighty percent of all admissions to hospital for fracture neck of femur are in females, why? 15. What factors may come into play when the numbers of babies born to teenage mothers per 1000 falls? 16. Can you think of any condition for which incidence is low but prevalence is high?
    • REFERENCES AND INFORMATION SOURCES Allen C (1993) ‘Water, water everywhere….’ Nursing Times June 23rd vol89, no 25 p.25 Barker D, Rose G (1991) Epidemiology in Medical Practice (4th ED.) London Churchill Livingstone Department of Health (1998) Saving Lives: Our Healthier Nation London HMSO Harkness G (1995) Epidemiology in Nursing Practice USA Mosby Helman C G (1990) Culture, Health and Illness Wright, London 2nd ed. (ch.12 Cultural factors in Epidemiology) Vetter N. Matthew I. (2000) Epidemiology and Public Health London Churchill Livingstone Other sources of information and data District / County Council web pages Public Health Report available from local departments of public health or via the internet Census information broken down by ward or post code available from local town halls/ regional council offices. GP practice age sex register. Some Practices have very detailed information available on computer . DETR web site: www.regeneration.detr.gov.uk
    • GUIDED STUDY: NURSING THE PATIENT WITH CARDIAC PROBLEMS (i.e. hypertension, cardiac failure, ischaemic heart disease, including cardiac failure.) In previous modules you have covered the anatomy and physiology of the cardio- vascular system. The aim of this guided study is for you to relate this previous learning to the common physiological problems that affect the heart and vascular system. The study takes you through a typical scenario and helps you explore the implications of the pathological changes. You will be expected to feed back your answers during one of the module taught study days. Scenario Mr John Huxtable, a 50 year old factory worker, is married and has two teenage children who live at home. He goes to the pub three nights a week and smokes 20 cigarettes a day. He enjoys “everything with chips” and is 10 kilograms overweight He visits his GP complaining of headaches and it is discovered that his blood pressure is 160/105 Activity1: What factors should his GP check to ensure he is recording Mr.Huxtable’s blood pressure accurately? Activity 2: Define 1) Primary or essential hypertension 2) Secondary hypertension. Activity 3: Which aspects of Mr. Huxtable’s life and life-style may be influencing his blood pressure? As a practice nurse running a hypertension clinic, what health promotion advice might you give Mr. Huxtable? What other interventions might you consider? Activity 4: Over the next six months Mr. Huxtable is prescribed diuretics, and calcium antagonists. a) What actions and side effects may each have. b) What information should he be given about his medication? Activity 5: Beta blocking drugs are frequently prescribed for hypertension Explain the action of beta blocking drugs and suggest why they may be considered unsuitable for Mr Huxtable Six months later Mr. Huxtable started getting chest pain walking up the hill to the pub, and is diagnosed as having angina pectoris. Activity 6: What is the nature and cause of anginal type pain?
    • Mr. Huxtable is given glyceryl trinitrate tablets (GTN) to put under his tongue. As his practice nurse, how would you reinforce the correct use of this medication? Explain how trinitrates act, and the side effects that Mr. Huxtable should be warned to expect. Mr Huxtable is informed by his Doctor that he now has “furred up arteries to his heart”. He continues to cope with most of his daily activities, taking his GTN sub- lingually only if episodes of chest pain occur. However, he has noticed he gets breathless going up stairs and on activities that take effort. He woke up at three o’clock one morning gasping for breath, wheezing and coughing frothy sputum. Mrs Huxtable rang the duty Doctor who called, and made a diagnosis of Left Ventricular Failure due to Mr Huxtable’s history of hypertensive heart disease. Activity 8: Explain the patho-physiological changes that have caused Mr Huxtable’s current problems. The General Practitioner administers Frusemide 20mg intravenously that quickly helps his breathing difficulties. Activity 9: Explain the action of Frusemide Mr Huxtable accompanied by his wife were transferred by ambulance to the District General Hospital for further treatment.. Activity 10 Outline the main priorities of treatment and care for a patient with acute left ventricular failure. Mr Huxtable is discharged home after a week. He remains breathless on exertion but is able to maintain his usual activities. He is put on the waiting list for cardiac surgery, however over the next few months he has two further admissions for Left Ventricular Failure. Since his last admission he has become increasingly tired and breathless and has lost his appetite. He has also noticed that sitting around all day his feet and ankles get too swollen for his shoes. This morning, Mrs Huxtable called in her General Practioner because Mr Huxtable felt too lethargic to get out of bed. The General Practioner finds that there has been a considerable deterioration in Mr Huxtable’s condition. He now appears to have ascites and an enlarged liver. His pulse is irregularly irregular. The GP arranges for immediate transfer to Hospital where a diagnosis of Congestive Cardiac Failure with atrial fibrillation is made. Activity 11: Explain the pathophysiology of the clinical features highlighted above. Mr Huxtable is prescribed Digoxin 0.25 mg, Frusemide 40mg, and potassium supplements. Activity 12: Explain the actions of these drugs.
    • Activity 13 Using the a framework for care that you are familiar with, write down the expected assessment data that you would obtain from a patient suffering from Congestive Cardiac Failure and then devise a care plan which would meet Mr Huxtable’s identified problems/needs. Suggested Reading Alexander M. et al (2002) Nursing Practice Hospital & Home. The Adult Edinburgh. Churchill Livingstone BMA (1997)The New Guide to Medicines & Drugs Goldalming. The Colour Library Direct Collins T. (2000) Understanding shock august Nursing Standard 23/vol 14/no49 Hand H. (2001) Myocardial Infarction Part 1 Nursing Standard 15(36) p45-55 Hand H. (2001) Myocardial Infarction Part 2 Nursing Standard 15(37) p45-55 Long, Phipps & Cassmeyer (1995) Adult Nursing: A Nursing Process Approach London. Mosby Prosser S. Et al (2000) Applied Pharmacology London Mosby RCN Nursing Update Heart Health: Prevention Learning Unit 074 Nursing Standard Oct 1 Vol12/Number 2/ 1997 RCN Nursing Update On the way up: Hypertension Unit 080 Nursing Standard March 18/ Vol12/Number 26/ 1998 Tortora & Agnostikos Principles of Anatomy & Physiology New York Harper & Rowe Underhill D. (1999) The uses of pulse oximetry Nursing Standard Nov 3 /14/7 Devised by Chris Wheeler & Marian Gillard (1998), updated September 2001 by Chris Wheeler
    • Guided Study: Health Promotion Work Book In module NUR 118 you were introduced to the concepts of health and health promotion. This study guide aims to build on these concepts and introduce you to different ways of thinking about how you plan and carry out health promotion activities. The objectives are to: 1. Define Health Promotion 2. Describe the various approaches to health promotion 3. Explain two Models of Health Promotion which underpin practice. 4. Identify ways in which you might help people to change Standards developed by the National Service Framework for Coronary Heart Disease (DOH 2000) will be used as examples throughout this study guide
    • Defining Health Promotion How Health Promotion is defined depends on an individual's concept of health. This can be a positive concept that defines health as a state of wellbeing or a negative concept, which defines health in terms of absence of illness and disease. Even though there are differences in theories and concepts relating to health, Seedhouse (2001) suggests that there is a common underlying factor: '' All theories of health are designed to increase health by advising against, preventing the creation of, or removing obstacles to the achievement of human potential. These might be biological, environmental, societal, familial or personal.'' Health is a positive concept which means different things to different people. The ability of people to reach their optimum level of health depends on a wide range of factors which can be defined as the determinants of health (Ewles and Simnett 1999) Activity: List the main determinants of health The WHO's definition of Health Promotion encompasses the need to improve health and for individuals to have more control over it. '' Health Promotion is the process of enabling people to increase control over, and to improve, their health'' (WHO 1984). The development of health promotion has progressed with recognition that improving health is not just about individuals changing their own behaviours but also involves social, political and environmental change. The concept of empowerment is integral to this definition which seeks to raise people's self-esteem by giving them the skills to be able to control their own lives. Current government strategy emphasises the importance of improving the health of everyone. However it also recognises that inequalities in health exist between those who are worse off and the need to address these (Our Healthier Nation, DOH 2000) There is also recognition that health promotion activities encompass the combined efforts of many agencies besides those in the health service and that collaborative working is more effective. Activity: State a number of different agencies and individuals that may be involved in health promotion activities. Differing concepts of health lead to different approaches to health promotion being used. These approaches can be recognised by their differing aims and methods. Often a person's approach to health promotion may be defined by their job role. However it is useful to consider if an alternative approach may produce an improved outcome. Our Healthier Nation (DOH 2000) identified Coronary Heart Disease (CHD) as a health priority and a National Service Framework (DOH 2000) has been developed for CHD to provide a quality service to prevent and treat CHD. For the purposes of
    • the following activities CHD will be used as an example to clarify health promotion activities. Five different approaches, as defined by Naidoo and Wills (2001) will be considered, these being, the medical approach, the behaviour -change approach, the educational approach, the empowerment approach, the societal change/ radical approach. Ewles and Simnett (1999) also define five similar approaches to health promotion but they replace the empowerment approach by the client-centred approach. Activity: Give examples of health promotion activities related to Coronary Heart Disease The Medical Approach Aims to reduce morbidity and mortality of medically defined disease Values expert led medical intervention The behaviour change approach Aims to encourage individuals to adopt healthier lifestyles by changing their attitudes and behaviour to those defined by 'experts' as being healthy. The educational approach Aims to provide knowledge so that individuals can make well informed decisions and choices about their health. Its prime aim is information giving not seeking to motivate people to change their behaviour. The empowerment approach This approach aims to work with people to identify their own health concerns and gain skills and confidence to address these concerns. It is a bottom up approach where the health promoter acts as a facilitator and not an expert. The societal- change approach The aim is to change society rather than individuals through focusing on economic, environmental and social policy changes. The emphasis is on making the healthier choice an easier choice.
    • Models of Health Promotion Theoretical models of health promotion have been developed to encourage a greater understanding of the philosophical underpinning of health promotion work. They provide an opportunity to critically examine practice and develop new ways of working. Tannahill and Downie (1990) Tannahill developed a model for defining, planning and doing health promotion. This model is widely used amongst health professionals. Tannahill's model consists of three overlapping spheres of activity: health education, health protection and prevention. It shows how each activity relates to the other. The principle underlying Tannahill's model is that of empowerment (Tannahill et al 1993) Health Education Prevention Health Protection
    • Beattie (1991) Beattie bases his model on four paradigms (different views) for health promotion which are developed from the mode of intervention and the focus of intervention. (see diagram below). The spectrum of the mode of intervention ranges from authoritative to negotiated and the focus of intervention from the individual to the group. From these, four strategies of health promotion are developed which are described as: Health persuasion encouraging individuals to change behaviours Legislative action campaigning for change in policy and legislation Personal counselling the health promoter works with the client acting as a facilitator to address the individuals needs as defined by themselves Community Development. working with community groups to address their health needs through empowerment and promotion of skills Authoritative Mode of Intervention HEALTH PERSUASION LEGISLATIVE ACTION Individual Collective Focus of Intervention PERSONAL COUNSELLING COMMUNITY DEVELOPMENT Negotiated Beattie (1991) Activity: Using one of the models described above apply it to promotion of health and prevention of CHD as described by the National Service Framework for CHD (2000), eg smoking, healthy eating, physical activity, obesity. Helping People Change
    • Health behaviours are important in predicting mortality and longevity of individuals. Much of a health professional's work in health promotion involves helping people to take on new health behaviours to promote a healthier life-style. A major focus of helping people change is recognising their right to freedom of choice to take on new health behaviours. Barriers to change and how they can be overcome also need to be considered. Many psychological theories may aid the practitioner in understanding how and why people choose the health behaviours they exhibit eg Becker's Health Belief Model (1970), Azjen and Fischbein's theory of Reasoned Action (1975). A useful model which may clarify your thinking about health related behaviour change is Prochashka and DiClemente's (1982) Stages of Change Model. Stages of Change Model (Prochaska and DiClemente 1982) This is a practical model which explains how change might take place rather than what contributes to the change. It identifies a number of stages an individual may go through when trying to change a behaviour (see diagram below). It may be used to guide health professionals in working with clients who are carrying out health damaging behaviours such as smoking or drug addiction. Exit Maintaining Action: ‘safer’ lifestyle Making changes Maintenance; Maintaining change Commitment: Ready to change Relapse: Relapsing back Contemplation: Precontemplation: Thinking about Not interested in change changing ‘risky’ behaviour Consider how this model might be used with a client who is a smoker or who is obese which are risk factors related to CHD.
    • Planning Health Promotion Health Promotion is a planned activity for which Ewles and Simnett(1999) have devised a set of steps which need to be considered before carrying out any health promotion work. These are illustrated in the flow chart below. Planning and Evaluating Health Promotion Identifying needs and priorities | Set aims and objectives | Decide the best way of achieving aims | Identify resources | Plan evaluation methods | Set action plan | Action (Ewles and Simnett 1999) Regardless of whether your Health Promotion Activities are planned events or opportunistic encounters it is important to ensure that you understand what you are trying to achieve, how you intend to achieve it and how you will know whether you have been successful. Activity: Consider a Health Promotion topic related to Coronary Heart Disease e.g. smoking behaviour and plan a health promotion activity using the above plan. References and Further Reading Ewles I and Simnett (1999) Health Promotion: A Practical Guide Middlesex Scutari press Kerr J.(ed) (2000) Community Health Promotion London, Balliere Tindall Naidoo J and Wills J (2000) Health Promotion Second Edition London, Balliere Tindall Seedhouse (2001) Health: The Foundations for Achievement Second Edition Chichester, Wiley
    • Diabetes Workbook Although this workbook will mention both Type 1 and Type 2 Diabetes Mellitus, the main focus will be Type 2 Mr Smith is a 50 year old office worker. He lives with his wife and two teenage children in a semi-detached house in suburbia. He drives to work and spends most of his day in front of a computer. In his leisure time he enjoys watching television and playing in the darts team at the local pub. Mr Smith is overweight. He has recently found that he is often thirsty and tired. He also has to pass water more frequently than he used to do. He decided to consult his GP. On investigation his GP found his blood glucose reading to be 12mmols/l. His blood pressure was 130/95 and his BMI 28. Mr Smith was asked to return the next day for a fasting blood glucose, which was found to be 9mmols/l. His lipid profile was normal. What is the normal range for pre-meal blood glucose? Explain how blood glucose is normally controlled in the body Mr Smith was diagnosed as having Type two Diabetes Mellitus. What are the two main types of Diabetes Mellitus? Write a short paragraph about each type explaining the epidemiology and causation of these types Can you name any other types of diabetes? After his GP's assessment and examination Mr Smith was referred to the practice nurse who discussed the importance of a healthy diet with him. He was also advised about sensible drinking and the benefits of moderate exercise. What type of diet would have been recommended to Mr Smith? Mr Smith's care would be shared between the Primary Care team at his surgery and the diabetes team at the hospital. Who might be the members of the diabetes team? He was also taught to monitor his blood sugar on a regular basis using a blood glucose monitor.
    • Name three important points to ensure accurate blood glucose monitoring occurs Mr Smith returned to see his GP after 3 months. Although he had lost some weight and his blood pressure was now 120/85 his blood glucose remained outside of normal limits despite a modified diet and increased exercise. The GP prescribed a hypoglycaemic medication for Mr Smith to stabilise his blood sugar. What are the two main categories of hypoglycaemic agents? What are their properties, dosage and cautions? It was also important that Mr Smith’s blood pressure was monitored and maintained within normal limits. The UKPDS (United Kingdom Prospective Diabetes Study 1998), confirmed the importance of normo-glycaemia and normo-tension in prevention of complications from Diabetes Mellitus. Access the UKPDS Study and consider its recommendations. Although Mr. Smith’s blood glucose was maintained within normal limits with hypoglycaemic medication there is always the possibility that he may need insulin in the future What are the main complications that can occur for a patient with Diabetes Mellitus? Mr Smith’s blood glucose is now within normal limits. His blood pressure is now 120/85. He comes regularly at 6 monthly intervals to see the practice nurse/ GP for monitoring and advice. The nurse discussed with him the importance of his diet, medication and exercise. What regular screening procedures would also be implemented to monitor and prevent any diabetic complications? Diabetes Mellitus has been recognised as a major health problem in the Western World and the numbers of people diagnosed with diabetes is increasing. The St. Vincent Declaration was produced in 1989 to lay down guidelines for improving health and reducing complications attributed to diabetes. More recently The National Service Framework for Diabetes has been developed (DOH 2002) to ensure quality and equity of service both in the prevention and treatment of diabetes mellitus. A major focus of this document is the Promotion of Health in improving quality of life to prevent Diabetes Mellitus and also in the prevention and reduction of complications caused by Diabetes Mellitus. Which groups of people are particularly at risk of having diabetes? mellitus? Access the National Service Framework for Diabetes Mellitus. What are the 12 key standards that this document covers? Consider how these standards are being met in Primary Care from what you have experienced in practice.
    • References Department of Health (2002) National Service Framework for Diabetes http://www.doh.gov.uk/nsf/diabetes/ Krentz A. and Bailey C. (2001) Type Two Diabetes in Practice London, Royal Society of Medicine Medical Press St Vincent Declaration (1989) in Krentz A. and Bailey C. (2001) Type Two Diabetes in Practice London, Royal Society of Medicine Medical Press. United Kingdom Prospective Diabetes Study (1998) Several reports in Lancet, BMJ. Williams G. and Pickup J. (1999) Handbook of Diabetes Second Edition Oxford, Blackwell Science