Answer

Chronic Care across the Lifespan B

Part A: Collection of Cues and Recalling of Knowledge

Collection of Cues and Information

            Mr. Noel Smith, a 55-year-old retired mining manager was diagnosed with asthma 20 years back. Clinical presentation of asthma includes a cough, wheezing, shortness of breath, which may worsen at night. The patient reports having obstructive sleep apnea (Sinyor & Concepcion, 2020). The patient reports experiencing chest tightness and difficulty in breathing, which may be attributed to airway obstruction. Asthma is a chronic condition that affects the lungs; thus, signs and symptoms are associated with dysfunction of the respiratory system (Sinyor & Concepcion, 2020). Smith’s signs and symptoms have been recurring. Reversible airway obstruction is the basis for recurrence of reported symptoms such as dyspnea, wheezing, and coughing (Sinyor & Concepcion, 2020).  He presented to the local Emergency Department with an audible wheeze which has been increasing for the past 24 hours before hospitalization as well as marked dyspnoea. Besides, he reported that over the previous 5 years, his episodes of wheezing and coughing have been increasing with frequency.

Information Processing

According to Sinyor and Concepcion (2020) there is significant relationship between smoking and heightened risk of asthma. Smith, reportedly, smokes 30 cigarettes in a day, which may have contributed to progressive worsening of asthma. There is evidence that there is positive linear correlation between body mass index (BMI) value and asthma (Sinyor & Concepcion, 2020).  In the presented case, Smith’s obesity (BMI= 30.7) may be playing a role in asthma exacerbation and deterioration with time. The observed reduced air entry and talking in short sentences is due to airway inflammation and bronchoconstriction, which have resulted in intermittent airway obstruction. Airway obstruction increases the work of breathing; hence, Smith’s respiratory rate (RR) (32 breaths per minute) has been elevated as a compensatory mechanism (Sinyor & Concepcion, 2020). Reduced oxygen saturation level (SpO₂ 92%) is an indication of compromised respiratory function due to airway obstruction (Fergeson, Patel, & Lockey, 2016).

 Apart from tachypnea (RR=32 bpm), tachycardia (heart rate= 110 beats per minute) suggests severe airway obstruction in this case (Sinyor & Concepcion, 2020). Tachycardia may have in turn resulted in high blood pressure (BP=155/95) in this case. However, Smith has history of hypertension; thus, observed hypertension may be merely primary hypertension. Smith’s asthma may be at the moderate stage since he has been experiencing an audible wheeze and marked dyspnea for the past 24 hours (Sinyor & Concepcion, 2020). It is also observed that Smith is using accessory muscles of breathing, which is one of the pathophysiological presentations of asthma (Fergeson, Patel, & Lockey, 2016).

Part B: Identification of Problems, Establishing of Goals, Taking Action and Evaluation of Outcomes

Identification of Problems and Issues

            Key acute and chronic problems or issues for Smith include poorly managed asthma and hypertension. Besides, he has history of hypercholesterolemia, seasonal hay fever, and gastroesophageal reflux disease.  History of obstructive sleep apnea is positively correlation with poorly managed asthma (Sinyor & Concepcion, 2020). Other signs and symptoms such as use of accessory muscles of breathing, breathing, chest tightness, and a productive cough also suggest poorly managed asthma and asthma exacerbation (Fergeson et al., 2016; Sinyor & Concepcion, 2020). High fat intake and history of hypercholesterolemia is associated with worsening lung function and airway inflammation (Alwarith et al., 2020). On the other hand, poor medication adherence is another major factor that contributes to poor prognosis and frequent exacerbation of asthma (Engelkes et al., 2015). High salt intake contributes to poor prognosis in treatment of hypertension (Ma, He, & MacGregor, 2015). On the other hand, high salt intake is an independent risk factor for obesity (Ma, He, & MacGregor, 2015), while obesity is associated with airway response to corticosteroids (Guilleminault et al., 2017).

Establishment of Goals

            Key treatment goals of Smith include the following. The first goal is establishment of Smith’s personalized asthma plan together with patient education to improve adherence to the treatment plan and medications (Kouri et al., 2017). The second goal is to achieve diet change through reduced intake of salt and avoidance of saturated fats to improve prognosis of asthma and hypertension (Guilleminault et al., 2017). The third goal is to weight loss till his BMI is below 25 to improve asthma treatment outcomes (Sinyor & Concepcion, 2020). The fourth goal is complete cessation of smoking behavior for at least three months to reduce frequency of exacerbation of asthma and hospitalization (Sinyor & Concepcion, 2020).

Taking Action

            Patient education is indicated in this case. The patient needs to be educated about the basis and usefulness of asthma action plan. He reports that he lacks understanding of the purpose and how to use asthma action plan. Besides, a developed asthma plan for this patient should be reviewed by a physician on a regular basis. Asthma action plan is a written individualized plan that is the developed by healthcare professionals for an asthmatic patient. Asthma action plans helps to improve quality of life and can reduce utilization of healthcare services (Kouri et al., 2017). A nurse should actively involve Smith during development of his asthma action plan to promote his engagement and adherence to the plan.

            He also requires dietary education and advice in relation to asthma and other chronic conditions. Smith needs to develop an understanding that saturated fat intake contributes to deterioration of lung function and airway inflammation (Alwarith et al., 2020). Besides, poor dietary practices such as high intake of processed and red meats, refined grains, and desserts increases airway inflammation, since they are associated with pro-inflammatory effects (Guilleminault et al., 2017). He should be advised to consider Mediterranean diet, with high intake of vegetables and fruits since they have anti-inflammatory properties (Guilleminault et al., 2017).  The patient is also in need of education and training on appropriate inhaler techniques and adverse effects of prescribed medications (Fergeson et al., 2016).

            Smith needs to also acknowledge the association between obesity and asthma. Obese patients with asthma tend to manifest with low allergen sensitization and low eosinophilic inflammation. Of more interest is that obesity contributes to reduced airway responsiveness of inhaled corticosteroids (Guilleminault et al., 2017). Other strategies that can improve prognosis are his chronic conditions include frequent physical exercises and weight loss. Smoking cessation is a necessity since cigarette smoke is a positive risk factor for development of asthma and deterioration of the condition with time (Sinyor & Concepcion, 2020). Reduction and possibly stopping intake of alcohol is also indicated so as to important to help Smith improve his mental, physical and social well-being.  Consumption is associated with increased allergic sensitization and development of asthma. Alcohol increases blood concentration of immunoglubin E, which is an important modulator of inflammation (Skaaby et al., 2018).

Evaluation of Outcomes

            Measures that may indicate effectiveness of Smith’s action plan include reduced asthmatic exacerbation; through reduced frequency of presentations of symptoms.  Besides, measures such as reduced utilization of healthcare services, improved adherence to prescribed medications, and reduced cost of care, can be used as effective indicators for effectives of the action plan. Besides, improved adherence to medications can also indicate impact of the provided patient-centered education. The above measures can also be used to evaluate the effectiveness of dietary advice and education. Reduced BMI from the current value of 30.7 can act as an indicator of weight loss; in part due to reduced salt intake and intake of saturated fat (Alwarith et al., 2020; Guilleminault et al., 2017). Similarly, reduced salt intake in diet will result in improve prognosis of hypertension treatment (Ma et al., 2015).

Monitoring and evaluation through follow-up is required to help the multidisciplinary team determine whether Smith has completely stopped smoking for at least three months and relate it with outcomes such as frequency of exacerbation of asthma and frequency of hospitalization due to asthma (Sinyor & Concepcion, 2020). Improved level of oxygen saturation rate (>95%) on room air will also be an important indicator for improved prognosis of asthma (Fergeson et al., 2016). In addition, good response to asthma treatment will be demonstrated by no dyspnea or wheezing for about a week and peak expiratory flow ≥80% (Fergeson et al., 2016).

Part C: Contemplation/Reflection on New Learning

            Nurses have a role to facilitate a self-management and self-efficacy for patients and their families, who are living with chronic conditions such as asthma in this case. The objective is to improve quality of life and health outcomes. Asthma is a chronic disease that requires adherence to appropriate to a medical treatment for achievement of desirable outcomes (Druedahl et al., 2018). Patient education plays an important role in promote of a patient’s ability to manage own medications as self-efficacy and self-management. Education helps to transform asthmatic patients to be experts in management of their own chronic conditions (Druedahl et al., 2018).

            Nurses have access to and can utilize technological resources to reduce morbidity and mortality due to a chronic disease. Technologic resources increase efficiency of healthcare workers to improve patient’s self-management and self-efficacy abilities. Besides, use of technology such as e-health in provision of healthcare services and patient education is associated with improved patient satisfaction of care (Poowuttikul & Seth, 2020). On the other hand, web-based asthma self-management strategies have been demonstrated as having a positive impact in improving quality of life, lung function, self-reported asthma symptoms, self-reported adherence, and reduction in asthma exacerbations or symptoms (Poowuttikul & Seth, 2020).

            Nurses can participate in dissemination of asthma information and information for other chronic via social media platforms such as Facebook. Social media is a common channel used for increasing public awareness and disseminating important health information. Social media can facilitate improvement of asthma self-management in patients in a friendly manner. Utilization of social media has been shown to improve patient self-esteem and asthma control test scores (Poowuttikul & Seth, 2020). In addition, mobile applications have an important role in promotion of medication adherence, quality of life, and reducing overall cost of asthma care. Apart from participating in social media platforms; nurses can also contribute significantly in creation of asthma content that is channeled via mobile applications (Poowuttikul & Seth, 2020). Some of the important applications that have been developed for mobile are inhaler trackers that help to improve adherence to prescribed medications (Poowuttikul & Seth, 2020).