The Management of COPD in Primary & Secondary Care
Perspectives on Death and Dying
ISBN: 978-1-905539-28-4
ISBN: 978-1-905539-21-5
The Clinician’s Guide to Chronic Disease Management for Long-Term Conditions: A cognitive-behavioural approach
Nurses and Their Patients: Informing practice through psychodynamic insights
Edited by experts in the field, this volume will help you to develop some of the essential assessment skills that are needed to support patients with long-term conditions in both secondary and primary care settings. Whether you are at the beginning of your career or you are a more experienced healthcare practitioner, this book will give you guidance on how to use appropriate assessment tools and how to reflect on your experience from practice. Supporting patients with long-term conditions is not solely the domain of nurses. Although some examples have been given from a nursing perspective, this book will be useful to a wide range of practitioners who are interested in developing their assessment skills further.
ISBN: 978-1905539-31-4
ISBN: 978-1-905539-15-4
Available for download in eBook format If you have an Apple™ iPhone, iPod touch, iPad OR an Amazon™ Kindle Issues in Heart Failure Nursing ISBN: 978-1-905539-00-0
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Other Health & Social Care books from M&K include: The Management of COPD in Primary & Secondary Care ISBN: 978-1-905539-28-4
Issues in Heart Failure Nursing ISBN: 978-1-905539-00-0
The Clinician’s Guide to Chronic Disease Management for Long-term Conditions: A cognitive-behavioural approach ISBN: 978-1-905539-15-4
Nurses and Their Patients: Informing practice through psychodynamic insights ISBN: 978-1-905539-31-4
Spiritual Assessment in Healthcare Practice ISBN: 978-1-905539-27-7
Perspectives on Death and Dying ISBN: 978-1-905539-21-5
Research Issues in Health and Social Care ISBN: 978-1-905539-20-8
Identification and Treatment of Alcohol Dependency ISBN: 978-1-905539-16-1
Preventing and Reducing Aggression & Violence in Health and Social Care: A holistic approach ISBN: 978-1-905539-57-4
The ECG Workbook 2/e ISBN: 978-1-905539-77-2
Developing Advanced Assessment Skills: Patients with long-term conditions Edited by Ann Saxon and Sue Lillyman
Developing Advanced Assessment Skills: Patients with long-term conditions Ann Saxon and Sue Lillyman (editors) ISBN: 978-1-905539-18-5 First published 2011 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London, W1T 4LP. Permissions may be sought directly from M&K Publishing, phone: 01768 773030, fax: 01768 781099 or email:
[email protected] Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Notice Clinical practice and medical knowledge constantly evolve. Standard safety precautions must be followed, but, as knowledge is broadened by research, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers must check the most current product information provided by the manufacturer of each drug to be administered and verify the dosages and correct administration, as well as contraindications. It is the responsibility of the practitioner, utilising the experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Any brands mentioned in this book are as examples only and are not endorsed by the publisher. Neither the publisher nor the authors assume any liability for any injury and/or damage to persons or property arising from this publication. To contact M&K Publishing write to: M&K Update Ltd · The Old Bakery · St. John’s Street Keswick · Cumbria CA12 5AS Tel: 01768 773030 · Fax: 01768 781099
[email protected] www.mkupdate.co.uk Designed and typeset by Mary Blood Printed in England by H&H Reeds, Penrith
Contents List of figures and tables vi Contributors vii About the editors
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Acknowledgements viii Introduction ix
Chapter 1 1 Developing competence and skills in the care of long-term conditions Ann Saxon and Sue Lillyman
Chapter 2 17 Supporting people with long-term conditions Sue Lillyman and Ann Saxon
Chapter 3 31 Assessment of patients with long-term conditions Sue Lillyman
Chapter 4 49 History-taking and clinical assessment Ann Saxon
Chapter 5 59 Assessment of patients with chronic respiratory disease Ann Saxon and James Bethel
Chapter 6 71 Assessment of patients with chronic heart failure Ann Saxon and Sue Lillyman
Chapter 7 87 Assessment of patients with diabetes mellitus Ann Philp and Ann Saxon
Chapter 8 101 Assessment of patients with musculoskeletal pain Mary Drodz and Gail Parsons
Chapter 9 113 Assessment of patients with multiple sclerosis Amanda Andrews and Sue Lillyman
Index
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List of figures 5.1 Chest palpation 65 5.2 Chest percussion 65 6.1 Visual analogue scale (VAS) for degree of breathlessness 76 7.1 Foot pulse examination 93 8.1 Knee examination 109 9.1 Neuron 115
List of tables 3.1 Examples of objective and subjective data 32 4.1 The SOAPIE model 56 4.2 The SOCRATES assessment 57 6.1 New York Heart Association (NYHA) system of classification 76 9.1 Sensory and motor function of the cranial nerves 120
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Contributors Amanda Andrews (Senior Lecturer) Birmingham City University James Bethel (Senior Lecturer) University of Wolverhampton Mary Drozd (Senior Lecturer) University of Wolverhampton Sue Lillyman (Senior Lecturer) University of Worcester Gail Parsons (Advanced Nurse Practitioner Orthopaedics) The Dudley Group of Hospitals NHS Trust Ann Philp (Head of Recruitment, Retention and Employability) University of Wolverhampton Ann Saxon (Principal Lecturer) University of Wolverhampton
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About the editors Ann Saxon SRN NDN Cert MA (ed) BSc (Hons) Health Science RNT Ann is a principal lecturer at the University of Wolverhampton. She has been a qualified nurse for over 30 years, specialising in community nursing. She was instrumental in setting up the first PG Cert Case Management for people with long-term conditions in partnership with Birmingham City University. Her research interests are patients’ experiences of case management and service evaluation.
Sue Lillyman SRN RM MA(ed) BSc (Nursing) DPSN PGCE RNT Sue is a senior lecturer at the University of Worcester. She has over 30 years experience as a nurse and nurse educator. She was the route director for the PG Cert Case Managers programme in partnership with the University of Wolverhampton. Her research interests are patients’ experiences of case management, service evaluation and caring for older adults.
Acknowledgements The authors would like to thank all those who contributed to the development of this book, in particular Hilary Kemp and Barbara Mason, and their families and friends who have always supported their endeavours. We would also like to thank the publishers, M&K Update, and Maria for her editorial skills.
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Introduction This book will help you to develop some of the essential assessment skills that are needed to support patients with long-term conditions in secondary and primary care settings. You may be at the beginning of your career, or you may be an experienced practitioner who is moving into long-term conditions care. At whatever level you may be, this book will give you some guidance on how to use appropriate assessment tools and to reflect on your experience from practice. Supporting patients with long-term conditions is not solely the domain of nursing. This book is intended to be suitable for a range of practitioners who are interested in developing their assessment skills further. However some examples have been given from a nursing perspective. The exercises throughout the book have been designed to encourage you to reflect on your practice and draw from the wide range of evidence that is available to support your development. You can work through them at your own pace and return to chapters that you need to learn more about.
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Chapter 1
Developing competence and skills in the care of long-term conditions Ann Saxon and Sue Lillyman
Key areas Meeting patient needs and models of care Self-assessment of strengths and weaknesses Reflective journals and learning contracts Resources and developing skills
Introduction It is estimated that 17.5 million people in the UK report living with a longterm condition (Department of Health, 2005). As we live longer, with better medical provision and living conditions, this is expected to rise to 18 million by 2025 (Department of Health, 2008) in people aged over 65 in England. It is currently around 15 million for this age group. Our ageing society has also been affected by the baby-boom generation of the post-war era and increased life expectancy. The Department of Health (2008) stated that: Long-term conditions are those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with a long-term condition is forever altered – there is no return to normal. Common conditions include: • Coronary heart disease, heart failure, stroke, transient ischaemic attacks a nd hypertension.
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Ann Saxon and Sue Lillyman • Diabetes. • Chronic obstructive pulmonary disease and asthma. • Epilepsy. • Cancer. • Chronic kidney disease. • Multiple sclerosis and motor neuron disease, Parkinson’s disease, dementia, schizophrenia and depression.
Exercise 1.1 List the most common conditions your patients present with. How does your list compare with above list?
Meeting the needs of people with long-term conditions People may be at risk of developing a long-term condition or chronic illness due to a variety of factors. First there is genetic makeup, for example some people are susceptible to motor neuron disease or certain types of cancer. And it could be the result of lifestyle. For example, people who are obese could develop diabetes and people who smoke could develop chronic obstructive pulmonary disease. However, genetic make-up and lifestyle are not the only factors. Many causes remain unknown. Once people are diagnosed with a long-term condition then care must be provided and coordinated to help the person live with that condition. The UK Government (Department of Health, 2005; cited by Baines, 2008) identified that the care needs of patients with long-term conditions should be divided into three levels: Level 1: This is aimed at encouraging people to self-manage and selfcare. They estimated that 70–80 per cent of this patient group would be in this category. Level 2: Level 2 involves the support of a multidisciplinary team (MDT)
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Developing competence and skills in the care of long-term conditions approach and includes people with single or multiple conditions. These patients are at risk of complications of their conditions and require some proactive management. Level 3: Level 3 targets those patients with highly complex and/or multiple conditions who have had frequent unplanned admissions to hospital for exacerbations of their condition.
Generic model for long-term conditions The Department of Health (2011) outlined four aspects of care to support patients with long-term conditions. This model suggests the following interventions: • Case management. • Personalised care planning. • Supporting self-care. • Assistive technology. These are also in line with the document entitled Liberating the NHS (Department of Health, 2010). Case management is the cornerstone of effective care and for the purpose of this book the roles of the community matron and case manager are therefore synonymous. This book will enable you to further develop your assessment skills for patients living with a long-term condition and it will assist your understanding of the interventions and what they may mean for you and your team. In order to start reviewing your development you may want to commence with a selfassessment or reflection on your current job or role.
Self-assessing your strengths and weaknesses Identifying our own strengths and weaknesses can be pretty daunting. We are often only required to consider this when we are attending a formal course or undergoing a job appraisal. However, it can be beneficial to your development to carry this out on a regular basis using some of the tools noted below. In developing a portfolio of skills it is vital that you are able to provide evidence of how you have achieved competence in a specific area.
For further information, you may want to review the following link: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_4133997.
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Ann Saxon and Sue Lillyman In 2006, the Department of Health identified an education framework for use by community matrons and case managers. It set out a range of skills and competencies required of the role. The competency tool has nine domains and ten principles. It was envisaged that these competencies would also help to develop personal effectiveness when caring for patients with a long-term condition. Here are the nine domains it outlines: • Advanced clinical nursing practice. • Leading complex care coordination. • Proactive management of complex long-term conditions. • Management of cognitive impairment and mental well-being. • Supporting self-care, self-management and enabling independence. • Providing professional practice and leadership. • Identifying high-risk patients, promoting health and preventing ill health. • Managing care at the end of life. • Interagency and partnership working. Here are the ten underpinning principles of these domains: • Advanced practice. • Learning methods. • Recognising prior learning. • Inter-professional learning. • Mentorship and coaching. • Organisational governance. • Collaborative commissioning. • Assessment of competencies. • Clinical supervision and continuing professional development. • Supporting experienced hospital nurses to move into community matron roles. The framework was based on the principle that, wherever possible, learning should take place in the workplace. This is more likely to encourage learning in everyday practice. The National Health Service Knowledge and Skills Framework (Department of Health, 2004) has also enabled individuals to assess their own level of
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Developing competence and skills in the care of long-term conditions competence in other areas. Your own job description will include a range of competencies from the framework and you may be working towards achieving these in relation to caring for patients with a long-term condition. Fifty-three competencies relating to case management have been developed by the NHS Skills for Health (www.skillsforhealth.org.uk). They include the National Workforce Competencies and the National Occupational Standards for long-term conditions.
A list of the competencies can be found at: https://tools.skillsforhealth.org.uk/tools. The range of competencies could be reviewed against your own role in caring for patients with long-term conditions and help you to construct a development plan for the future. Here are examples of just a few of them: • Obtain information to inform the assessment of an individual. • Investigate and diagnose an unwell individual as part of clinical management of the long-term condition. • Enable individuals with a long-term condition to manage their medicines. • Enable people with long-term conditions to cope with changes to their health and well-being.
Exercise 1.2 Review a copy of your job or role description. Identify any key individual or team development.
Developing a reflective journal A reflective journal allows practitioners to monitor their own progress during episodes of care for patients with long-term conditions. It encourages a breadth and depth of learning to take place, developing a responsible and accountable practitioner (Ghaye and Lillyman, 2006) and effective clinical learning (Boud, 1985).
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Ann Saxon and Sue Lillyman Currently there are a multitude of models in the literature that have been developed for the healthcare professional (Ghaye and Lillyman, 1996, 2008; Gibbs, 1988; Johns, 2002; Kolb, 1984; Louden, 1981). It is up to the practitioner to decide which model suits their style of learning and to adapt that model within their practice. Gibbs (1988) is the most widely used model within nursing. It provides a cyclical approach to reflection, aiming to deepen awareness and increase knowledge as the practitioner moves through the six stages of the cycle. This model begins with a description of the event or experience, noting the feelings associated with that event, evaluating what was good and bad about the event, and analysing the situation. It concludes by noting what else could have been done and ends up with an action plan for future encounters of a similar situation. Although the model offers a constructive step-by-step approach it always tends to start with a problem and move from there. This can lead the reflection into negative aspects and tends to fail to offer reflection on positive aspects of care. It is important to recognise that our reflections may not always begin with an event or problem. In some cases, they may begin with the anticipation of an event, requiring an action plan to be developed prior to the situation occurring. Johns (2002) offers a model that is very structured and which also tends to relate to negative aspects of care. Johns uses cue questions to guide the practitioner through five groups of questions of the ‘What?’, ‘Why?’ and ‘How?’ type. He also advocates that the journey through reflection should be supervised or supported. Other less-frequently used models include the hierarchical models of Mezirow (1981) and Goodman (1984). In order to move from the negative to a more appreciative approach, Ghaye et al. (2008) developed what they refer to as the participatory and appreciative action reflection. This model comprises four essential mutually supportive processes. They start with what they refer to as an appreciative gaze. This involves looking at an experience or situation from a positive perspective. Next, they ask other professionals to reframe that experience by reviewing the problem or challenging it in a creative way. The third step involves building a practical wisdom by including local and regional ownership of the issues through productive thinking. The final step relates to the ethical and moral courage to use that way of thinking and action. Whichever model you choose to guide you through your reflection and practice, you need to be aware of the need to develop these skills and record them in your journal for future reference and in order to demonstrate your
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Developing competence and skills in the care of long-term conditions continuing professional development for your employer and the Nursing and Midwifery Council (NMC) requirements. In Exercise 1.3 we offer you some cues to guide you through your reflection, to help you to access, make sense of, and learn through experience.
Exercise 1.3 Description Write a description of an experience or thoughts about what you did (or might do) for a patient. What are the key issues within this description that you should pay attention to? Reflection What were you (or are you) trying to achieve? Why did you act as you did (or how might you act)? What were (or what may be) the consequences of your actions (a) for the patient and family, (b) for yourself, and (c) for the people you work with? How did you (or may you) feel about this experience when it happened (or happens)? How did (or may) the patient feel about it? How do you know how the patient felt (or may feel) about it? Exercise 1.4 is an alternative outline using some of the questions from Johns model of reflection (Johns, 2002).
Exercise 1.4 Influencing factors What internal factors influenced (or may influence) your decision-making and actions?
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Ann Saxon and Sue Lillyman What external factors influenced (or may influence) your decision-making and actions? What sources of knowledge influenced (or may influence) your decision-making and actions? Alternative strategies Could you have dealt better with the situation or are there any other alternative approaches? What other choices did (do) you have? What would be the consequences of these other choices? Learning How can you make sense of this experience in light of past experience and future practice? How do you now feel about this experience? Have you taken effective action to support yourself and others as a result of this experience? How has this experience changed your way of knowing in practice?
The value of reflective practice for professional development has been well recorded, and most practitioners see the value once they start receiving some form of support (Ghaye and Lillyman, 2006). It is important that time is put aside for this activity where possible. Identify your own style of reflection. Choose a model and identify one area of practice that you have been involved in. Ensure that at all times you maintain confidentiality, in line with professional body regulation (Nursing and Midwifery Council, 2005).
Exercise 1.5 What are the strengths of the model you have chosen? Can you identify any weaknesses of using the model? How can you use a model of reflection to demonstrate competence? How does this reflection relate to your case manager and knowledge and skills framework (KSF) competencies?
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Developing competence and skills in the care of long-term conditions Reflection can help you to identify specific areas for development in relation to the case manager’s competencies. For example: • Medicines management. • Assessment skills. • Advanced communication skills. • Working in partnership. • Managing conflict. By identifying your own thoughts and feelings related to a situation in practice it could enable you to identify your own leadership skills and how you participate in teamwork activity.
The following will also enable you to review your leadership skills against those outlined by the Department of Health (2006): http://www.nhsleadershipqualities.nhs.uk/. Reflecting and analysing individual cases will help you to be able to discuss your experiences, and the outcomes and differential diagnosis of a patient with others involved in the patient’s care, for example, reviewing case notes with a physician or other therapist. This will help to develop teamwork and seamless care for patients and their carers.
Developing a learning contract Learning contracts identify what people need to learn. They can be used in formal and informal settings, such as developing your skills as part of obtaining a qualification, for a job appraisal, or for identifying how you have met the knowledge and skills framework requirements in your ongoing professional development. It can help you to determine where you need to concentrate your efforts and where you need to access support from others. The learning contract provides a useful basis for: • Building an effective learning relationship. • Applying theory to practice. • Ensuring maximum benefit from practice experience. • Negotiating role development in accordance with the Knowledge and Skills Framework (Department of Health, 2004). Time taken to use skills of reflection through a learning contract will enable
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Ann Saxon and Sue Lillyman you to get the most out of a new learning experience. It can include learning objectives that can be negotiated with your employer to help you develop and maintain professional competence within your role (Beare, 1985). A learning contract: • Requires the professional to be self-motivated and self-directed. • Identifies learning outcomes, resources and strategies for learning. • Provides criteria and means for validating that learning has taken place. • Specifies the timeframe in which the contract will be undertaken. • Specifies who will evaluate, how and when.
Exercise 1.6 Identify a new skill that you would like to learn and write a learning contract. What resources will you need? Are they human or material? Have you set an aim and objectives? Have you considered a reasonable timeframe? How will you assess your success?
Resources There are a range of resources that would enable you to develop your competence in the care of patients with long-term conditions. These could be material or human. For example: • Attending a formal course. • Spending time with an advanced practitioner. • Spending time with another health professional. • Searching and critically appraising the literature. • Identifying evidence-based practice topics to explore. • Sharing your experience with others, formally and informally.
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Developing competence and skills in the care of long-term conditions
Developing a range of skills to support patients with long-term conditions In working with patients and carers who have a long-term condition, a range of skills are required to ensure that effective and efficient care packages are developed (Department of Health, 2005).
These are specified at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_4130725. You may have some of these skills as part of your own job description or you may be embarking on an educational programme that requires you to develop skills in the clinical area. Below is a list of learning outcomes that you may wish to review in light of your current role and identify any areas for development (Jester and Foxall, 2005). 1. Demonstrate an understanding of the pathophysiology relevant to a client with a long-term condition. 2. Demonstrate an understanding of the social and psychological factors contributing to the patient’s illness and illness behaviour. 3. Demonstrate the skills of history-taking and applied knowledge. 4. Demonstrate effective communication during the assessment process. 5. Demonstrate the ability to request and interpret appropriate diagnostic tests and investigations in accordance with local policy. 6. Demonstrate knowledge, skill and appropriate use of physical and mental health assessment tools in the assessment of patients with chronic disease. 7. Demonstrate knowledge, ability and skill in the use and selection of appropriate disease-specific general measures of health related to quality of life. 8. Conduct an assessment taking account of the patient’s condition and with respect for the patient’s privacy and dignity. 9. Demonstrate the use of appropriate evidence-based practice treatment and interventions.
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Ann Saxon and Sue Lillyman 10. Identify actual and potential problems following the initial assessment and subsequent data collection. 11. Identify and demonstrate the need to refer patients to other healthcare professionals when appropriate.
Exercise 1.7 Consider how you would demonstrate competence in some of the above areas. How may you go about learning some of these new skills? What resources may you need? You could achieve the objectives in Exercise 1.7 in many ways. For example: • By someone observing you in practice. • By discussing a particular case with a colleague. • By obtaining a written testimony from others to support your learning. • By attending a formal course or award. • By undertaking mentorship and coaching.
Advanced practice development The Nursing and Midwifery Council (2005) set out what advanced nurse practitioners (ANPs) should be able to provide in their role. They recognised that they are highly skilled nurses who can: • Take a comprehensive patient history. • Carry out a physical examination. • Use their expert knowledge and clinical judgement to identify a potential diagnosis. • Refer patients for investigations where appropriate. • Make a final diagnosis. • Decide on and carry out treatment, including the prescription of medicines, or refer to an appropriate specialist. • Use their extensive practice experience to plan and provide skilled and competent care to meet patients’ health and social care needs,
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Developing competence and skills in the care of long-term conditions involving other members of the healthcare team as appropriate. • Ensure provision of continuity of care, including follow up visits. • Assess and evaluate with patients the effectiveness of the treatment and care provided, and make changes as needed. • Work independently, although often as part of a health care team. • Provide leadership. • Make sure that each patient’s treatment and care is based on best practice. Further work was created by NHS Education for Scotland in 2008. They developed an advanced practice development needs-analysis toolkit. In this toolkit, they identify key areas that advanced practitioners should be working towards. They put forward three areas that you might use in your own competence development: 1. They suggest how you can rate the level of confidence that is pertinent to your role in practice, using the following guide: • I require training and development in most or all of the areas. • I require further training and development in some aspects of this area. • I am already confident in carrying out this objective competently. 2. They suggest that evidence is provided to demonstrate achievement of the competencies, and give some central themes, such as: • Leadership. • Facilitating learning. • Research and development. • Advanced clinical and professional practice. 3. They identify some underlying principles: • Autonomous practice. • Critical thinking. • Decision making and problem solving. • Values-based care. • Improving practice.
You may want to review the full toolkit using the link below: http://www.advancedpractice.scot.nhs.uk/toolkit-concept/overview.aspx.
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Ann Saxon and Sue Lillyman
Conclusion This chapter has given you an opportunity to review your current role and career aspirations in relation to caring for people with long-term conditions. You have had an opportunity to review models of reflection and choose one that you can use in relation to your knowledge and skills in this area of practice. You may wish to review your progress towards becoming an advanced practitioner in the area of long-term conditions. The remaining chapters will focus on furthering your assessment skills in this area of practice.
References and further reading Baines, S. (2008). The case managers challenge. In: S. Lillyman and A. Saxon (eds) Community Matrons: Caring for People with Long-term Conditions. London: Quay Books, pp. 9–17. Beare, P (1985). The clinical contract – An approach to competency-based clinical learning and evaluation. Journal of Nurse Education 24(2), 75–77. Boud, D.R., Keough, R. and Walker, D. (1985). Promoting reflection in learning: A model. In: D.R. Boud, R. Keough and D. Walker (eds) Reflection: Turning Experience into Learning. London: Kogan Page, pp. 18–39. Department of Health (2004). The NHS Knowledge and Skills Framework and the Development Review Process. London: Department of Health. Department of Health (2005). Supporting People with Long-term Conditions: An NHS and Social Care Model to Support Local Innovation and Integration. London: Department of Health. Department of Health (2006). Caring for People with Long-term Conditions. An Educational Framework for Community Matrons and Case Managers. London: Department of Health. Department of Health (2006). Leadership Qualities Framework. London: Department of Health. Department of Health (2008). Long-term Conditions Compendium of Information. Adding Life to Years and Years to Life. London: Department of Health. Department of Health (2011). Generic Long-term Conditions Model. London: Department of Health. Department of Health (2010). Equity and Excellence: Liberating the NHS. London: Department of Health. Ghaye, T. and Lillyman, S. (1996). An Introduction to Learning Through Critical Reflective Practice. Newcastle-upon-Tyne: Formword Publications. Ghaye, T. and Lillyman, S. (2006). Learning Journals and Critical Incidents, 2nd edn. Dinton: Mark Allen Publishing. Ghaye, T. and Lillyman, S. (2009). Principles of Reflection, 2nd edn. Dinton: Mark Allen.
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Ghaye, T., Melander-Wilkman, A., Kaisare, M., et al. (2008). Participatory and appreciative action and reflection (PARR). Democratizing reflective practices. Reflective Practice 9(4). 361–395.
Developing competence and skills in the care of long-term conditions Gibbs, G. (1988). Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Oxford Brooks University. Goodman, J. (1984). Reflection in teacher education: A case study and theoretical analysis. Interchange 15(3), 3–13. Jester, R. and Foxall, F. (2005). Postgraduate Certificate Case Management in Long-term Conditions Course Handbook. Wolverhampton: University of Wolverhampton. Johns, C. (2002). Guided Reflection. Advancing Practice. Oxford: Blackwell Scientific Publications. Kolb, D. (1984). Experiential Leaning: Experience as the Source of Learning and Development. London: Prentice Hall. Lillyman, S.J. and Saxon, E.A. (2009). Community Matrons. Caring for People with Long-term Conditions. Dinton: Mark Allen. Louden, W. (1981). Understanding Teaching. London: Cassell. Mezirow, J. (1981). A critical theory of adult learning and education. Adult Education 32(1), 3–24. Nursing and Midwifery Council (2005). Implementation of a framework for the Standards of Post-Registration Nursing: Agendum 27.1. C/05/160. London: Nursing and Midwifery Council.
Useful web resources Association of Advanced Nurse Practice Educators www.aanpe.org/AdvancedNursingPractice/tabid/721/language/en-US/default.aspx
Long-term Conditions Alliance Scotland (with information about living better with selfmanagement) www.ltcas.org.uk
NHS Skills for Health www.skillsforhealth.org.uk
The Nursing and Midwifery Council perspective on advanced care www.nmc-uk.org
Reflective Learning-UK website on reflective practices www.reflectivepractices.co.uk
Royal College of Nursing www.rcn.org.uk
Skills For Care helping social-care employers to improve their workforce www.skillsforcare.org.uk/workforce_strategy/workforce_strategy.aspx
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Chapter 2
Supporting people with long-term conditions Sue Lillyman and Ann Saxon
Key areas Case management models System levers The single assessment process Developing a workforce Advanced assessment skills
Introduction This chapter reviews the support that is offered to people (and their carers) who are living with one or more long-term conditions. It reviews the systems that can be incorporated, including models of case management, strategies for supporting people (such as the single assessment process) and advanced assessment skills.
Models of case management In response to the need for more supported and coordinated care, the UK Government set out its strategy for a model of Health and Social Care (Department of Health, 2005) where it identified the key components as: • Providing a flexible model where the primary care trust (PCT) and partner organisations work together to identify all patients with
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Sue Lillyman and Ann Saxon long-term conditions in the local health community through a case- management approach. • Stratifying the patients to match care to the different needs of patients. It is important to consider all of the practitioners who may be involved in a care package for people with long-term conditions, and how the pathway of care has been developed. This includes not just those working within health and social care but also the voluntary sector. It is important to consider the factors that influence the production and implementation of any models.
Some examples of care can be found on the Kings Fund site at www.kingsfund.org. Examples include self-management for long-term conditions, patients’ perspectives on the way ahead, the use of patient information in long-term conditions (for the combined predictive model), and others relating to selfmanagement, telecare and telehealth.
Exercise 2.1 Identify the model of care used in your practice area. Is this a case management approach and, if so, what other agencies are involved with the care delivery? What are the strengths, weaknesses, opportunities and threats for your model? Consider the barriers to effective implementation of a model of care for people in your area. How can you develop that service to overcome some of the barriers?
System levers for supporting people with long-term conditions In 2007, the Department of Health published an updated compendium of information. This was called Raising the Profile of Long-Term Conditions Care: A Compendium of Information. This set out a strategy for supporting people
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Supporting people with long-term conditions with long-term conditions and identified some of the system levers that can be used to support such people. These include: • National service frameworks. • Practice-based commissioning. • Assistive technology. • Payment by results (PbR). • The patient experience programme, NHS direct and digital TV. • The pharmacy contract. • Use of quality and outcomes framework. • Self-directed care and individual budgets. • Information technology (IT) systems. These levers will now be described one by one.
National service frameworks These were developed to provide practitioners with an evidence-based protocol and quality standards for those diseases that contribute mostly to mortality and morbidity in the UK. The areas they cover are cancer, coronary heart disease, diabetes, chronic obstructive pulmonary disease, mental health, older people, renal services and stroke. The aim of the frameworks is to promote better disease management through evidence-based protocols, and they are a means of establishing the minimum standards that should be set for specific diseases. They all promote better disease management, and each includes a set of quality standards.
These frameworks, including the long-term conditions framework, can be found at: www.nhs.uk/nhsengland/NSF/pages/nationalserviceframeworks.aspx.
Practice-based commissioning Practice-based commissioning was introduced by the government in 2005 (Department of Health, 2005). It devolved the responsibility for commissioning local services to the GP practices, who then had control over their budgets because they were the ones with clinical information about their populations at a local level. This practice-based commissioning, it was suggested, has the potential to allow GPs to fund services for people with the greatest need, depending on the health profile of the local area, and to design effective and appropriate health services. GPs also have the potential to invest savings
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Sue Lillyman and Ann Saxon that can be used in areas in which gaps for services are identified, as well as funding the high costs associated with patients with long-term conditions. In this way, they can make practical and innovative changes to care. However in 2009, the Primary Care Trust Network identified that this approach had not yet reached its full potential. Now the government is proposing within its new document Liberating the NHS (Department of Health, 2010a) that there is a move to devolve more power and responsibility to GPs and their practice teams by forming consortia, and that the money follows the patient. This, they claim, will put the patient at the heart of the NHS, and provide an opportunity to focus on improving things that really matter to the patient. It would also empower and liberate clinicians to be more innovative (Department of Health, 2010a).
For more information in relation to practice-based commissioning, see the Primary Network NHS confederation website at www.nhsconfed.org/publications.
Assistive technology Telecare and telemedicine are important new approaches to healthcare delivery within the UK. In 2006, the Department of Health provided £80 million in the form of ‘preventative technology grants’ to local authorities in order to assist them with implementing telecare and telemedicine facilities for older people within their homes. The aim of the devices is to reduce the risks associated with living at home, to allow prompt and appropriate responses of the emergency services, to manage specific conditions, to delay admission to residential and nursing care, and to enable safer discharge from hospital (Care Services Efficiency Delivery).
For more information see www.csed.dh.gov.uk. Horton (2008) also notes that this technology can be used to detect early changes, prevent deterioration, and help reduce hospital admission, as well as increasing quality of life for both the patients and their carers. Electronic devices are used to remind patients when to take tablets, and remote consultations and transmission of electrocardiograms and radiological images enable people to maintain independence in their own home and empower them to do more for themselves, to monitor their own condition and to access information (Horton, 2008).
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Supporting people with long-term conditions Payment by results (PbR) Through the NHS Plan in July 2000, the Department of Health allocated funding towards the activity of hospitals. They produced a system of payment by results in order to encourage an increased throughput of patients. This aimed to reward NHS Trusts for their efficiency, to support patient choice and diversity and to reduce waiting times. This system enabled commissioners of services to release funds from acute care and encouraged the NHS to reduce length of stay for patients, in particular those with a long-term condition who are usually high intensive-care users. This is ongoing, and in the period 2010 to 2011 four tariffs were introduced to support the wider healthcare policy of providing closer care at home. Further proposals for the NHS to work across organisational boundaries were set out in the Operating Framework for the NHS in England (Department of Health, 2011) and the health white paper Equity and Excellence: Liberating the NHS (Department of Health, 2010a).
The patient experience programme, NHS Direct and digital TV The patient experience programme was set up to identify the experiences of patients who access the NHS and how services can be improved. It aims to share good practice between different services and focuses on people receiving care in hospital, from the primary care services and those with long-term conditions.
Further information can be obtained from: www.bettertogetherscotland.com. NHS Direct service was set up in 1997 when the UK government set out to modernise the service, and it became a nationwide service. A 24-hour telephone advice service is provided, staffed by nurses and aiming to ‘provide people at home with easier and faster advice and information about health, illness, and the NHS, so that they are better able to care for themselves and their families’ (NHS Direct, 2011). In 1999 they went live on their own website to provide up-to-date health information, self-help guides, and a magazine called Mind and Body which covers current health news with discussions, items, features, quizzes and health tools. The website currently is visited over 1.5 million times every month (NHS Direct, 2010). With the introduction of digital TV, Stewart (2008) noted the potential of the system for information and communication. Through a digital ‘interactive medium’ it can be used in innovative ways to access a localised and
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Sue Lillyman and Ann Saxon personalised service with the aim of improving quality of life in a convenient way. The Scottish government is currently looking into access of health questionnaires via digital TV (Puttick, 2011). All these services are aimed at providing resources for patients to selfcare and self-manage their condition.
The pharmacy contract The NHS Community Pharmacy Contract was developed by the Department of Health, Pharmaceutical Services Negotiating Committee and the NHS Primary Care Contracting in 2004 in an attempt to save GPs’ time and broaden the services that pharmacists can offer (Pharmaceutical Services Negotiating Committee, 2006). They estimated that 80% of all repeat prescriptions could be handled by a community pharmacy, which would in turn reduce the workload of GPs, enhance the patient experience, and provide a more widely available service (Pharmaceutical Services Negotiating Committee, 2006). The contract is made up of three different services, namely essential services, advanced services and enhanced services (Pharmaceutical Services Negotiating Committee, 2006). Essential services: These cover repeat prescriptions, advice about dispensed medicines and their interactions with other medications, disposal of unwanted medication, promotion of healthy lifestyles, signposting patients to other healthcare providers, and support for self-care. Advanced services: These apply where there will be an accreditation of the pharmacist and pharmacy, providing services for medicine review and prescription intervention. They also provide locally commissioned services that assist people living with long-term conditions, such as minor diabetes screening, disease-specific medications management, palliative care services, full clinical medication review and care home services. Enhanced services: These services are contracted at a local level. The Pharmaceutical Services Negotiating Committee has developed a tool kit to assist local service providers.
Further information on the PSNC can be obtained from www.psnc.org.uk.
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Supporting people with long-term conditions Use of quality and outcomes framework The National Quality and Outcomes Framework (QOF) was introduced as part of the GP contract in 2004 (Department of Health, 2004). This framework rewards GP practices in England who are managing well, in particular regarding services for patients with long-term conditions. It will allow primary trusts to build on their success and improve services locally, rewarding them for the way in which they gain the views of their patients, how they organise their practice and the extra services they provide.
Further information can be found at the website of the NHS Information Centre for Health and Social Care at www.ic.nhs.uk
Self-directed care and individual budgets In 2008, the Social Care Institute of Excellence published Personalisation: A Rough Guide in which they identified new ways of producing a range of services that people can choose to support their own needs. These are tailormade to each person and paid for by individualised cash payments to the individual patient or client to pay for community care services within the local authority. Personal and individual budgets are provided alongside direct payments and are part of the personalisation agenda. A sum of money is allocated to the individual, who is assessed as requiring personal assistance and support. This directed care was set out to improve personal choices, promote independent living and improve the health and wellness of people. Through these individualised budgets, patients are able to self-manage their care and have the power to purchase services they feel will make a difference to their lives. This framework is in support of personalised care and care packages.
For further information see the Age UK website at: www.ageuk.org.uk
Information technology (IT) systems As information technology and management revolutionises the NHS, the Department of Health and National Patient Safety Agency have set standards for the use of IT systems and provide a Standards Enforcement in Procurement (STEP) tool for the use and purchase of IT systems to protect patient safety and
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confidentiality. A common assessment framework and electronic care record are being developed, building on the single assessment process to minimise duplication of work, to assist in sharing information, and to improve clinical decision-making. This system includes the risk-prediction tool and combined predictive model. The Electronic Prescription Service allows prescriptions to be sent electronically to a pharmacy.
Further information can be found at: www.connectingforhealth.nhs.uk
Exercise 2.2 Identify in your own local area what progress has been made in relation to the above levers for good health and social care systems. Are they shared across professional groups? Are they widely publicised? If so, make a list of services and contact details for your client group in your local area.
The single assessment process (SAP) This approach aims to deliver person-centred care that is then shared with other professionals. It was introduced in the National Service Framework for Older People (Department of Health, 2001) and derived from Nolan and Caldock’s (1996) work in relation to good practice. The process aims to ensure that the NHS and Social Care Services treat older people as individuals and enable them to make choices about their own care. This is achieved through SAP, integrating commissioning arrangements between health and social care and integrated provision of services. The requirement to develop SAP followed recognition that many older people have wide-ranging welfare needs, and that agencies need to work together to ensure that assessment and subsequent care planning are effective and coordinated.
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Supporting people with long-term conditions The SAP requires mutual trust, robust systems and a clear understanding of professionals’ roles and responsibilities (Department of Health, 2001). It was established to enable practitioners to work together and have a single point of access for assessment of need (Department of Health, 2002) whereby agencies coordinate their approach, share information more effectively, avoid duplication, and illustrate the intentions behind the Government’s approach to quality care (Swann, 2005). Key to the process are person-centred care, information management, effective use of resources, thorough and accurate assessment, and the avoidance of duplication for the professional and the patient. The SAP document is split into several sections to allow professionals to complete specific documentation and assessment required to deliver specialist care. Following an initial contact assessment, in which general personal data is collected, there is a specialist assessment for the professional to explore specific needs in depth. The documentation should then follow the patient through their contact with various healthcare providers, resulting in greater control for patients with respect to their needs and provision of care. For many people, a long-term condition is complex, affecting several aspects of their lives, from their activities of daily living through to finance and social aspects. It is essential that the documentation is easily accessible to all involved in their care and is completed in conjunction with the patients and their carers. The requirement to develop a single assessment process was based on the recognition that many older people have wide-ranging welfare needs and that agencies need to work together so that assessment and subsequent care planning are effective and coordinated (Department of Health, 2001). Such care is holistic and centres on the whole person. The involvement of patient and clients is fundamental to its successful implementation. However, as stated previously there are moves to gain and store this information electronically.
A worked example of the SAP is available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_4009402.
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Exercise 2.3 Identify the factors that influence your assessment using the SAP approach, based on the following key components: Physical Social Financial Environmental Medicine management Carer assessment
Many community practitioners have developed their skills using the SAP to facilitate care for patients with long-term conditions. They are mainly used by: • Community nurses. • Social workers. • Public health nurses. • Occupational therapists. • Doctors. • Physiotherapists. A collaborative approach ensures that care is coordinated and that everyone is involved in the process (Department of Health, 2001).
Developing the workforce for long-term conditions care Developing and transforming services is essential for keeping pace with change and for ensuring that a health and social care service is fit for purpose. The workforce is crucial for delivering the newly transformed services, and should update knowledge and skills accordingly. The Department of Health (2007) suggests that to achieve this they must: • Have the right skills, knowledge and competencies.
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Supporting people with long-term conditions • Communicate effectively. • Be able to identify people’s strengths and weaknesses. • Promote choice and independence. • Enable people to manage identified risks. • Provide relevant and evidence-based information. They go on to suggest that the right systems need to be in place to support partnership working across all agencies, including health and social care. They also point out that staff need to have the right attitude and behaviours. They should be: • Be encouraging. • Be supportive. • Be professional. • Offer advice. • Be respectful. In developing some of these skills, in particular around assessment, the following chapters will enable you to develop your skills and knowledge to support the long-term conditions agenda.
Advanced assessment skills Advanced assessment skills can be used by many practitioners to develop further comprehensive pathways of care. They are essential in the diagnostics and decision-making process of care, in particular when a patient is experiencing an exacerbation of an already complex condition such as chronic obstructive pulmonary disease or heart failure. It is essential that practitioners have the range of skills required to make decisions about the care of patients, and to know when it is necessary to refer on to more specialist services. According to the Nursing and Midwifery Council (2005). Advanced assessment skills include the ability to: • Take a comprehensive history. • Carry out a physical examination. • Use expert knowledge and clinical judgement to identify a potential diagnosis. • Refer patients for investigations.
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Sue Lillyman and Ann Saxon • Make a final diagnosis. • Decide on and carry out treatment, including the prescribing of medicines or referral of patients to an appropriate specialist. • Provide a comprehensive package of care, meeting patients’ health and social care needs. • Assess and evaluate with patients the effectiveness of treatment and care provided and make changes where necessary. • Work independently. • Ensure care and treatment is based on best practice. These advanced assessment skills can be used in conjunction with the Knowledge and Skills Framework for developing competence (Department of Health, 2004b) and in 2005 the Royal College of Nursing produced their guidance for nurses and managers in creating the Knowledge and Skills Framework outlines.
This guidance can be found at: www.rcn.org.uk The Department of Health’s competency framework for community matrons (2006) suggests other areas for development might include: • Advanced communication skills. • Advanced risk assessment and the management of risk. • Indepth knowledge of the pathophysiology of disease. • Sophisticated application of holistic person-centred care.
Conclusion The interventions noted in this chapter all aim to improve independent living for people with long-term conditions, so that those people can remain in their own homes for as long as possible. They aim to enhance the quality of the person’s life and that of their carers when living with one or more long-term conditions. These interventions strive to provide further support and provide information in an attempt to reduce the number of hospital admissions. These aims are in line with the UK Government’s public health strategies including the English Department of Health’s Healthier Lives, Healthy People (2010b), the Scottish Government’s Healthcare Quality Strategy (NHS Scotland,
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Supporting people with long-term conditions 2010) and Better Health, Better Care (2007), the Irish Government’s Investing for Health Strategy (2002) and the Welsh Assembly’s Our Healthy Future (The Welsh Assembly, 2010).
References and further reading Department of Health (2000). The NHS Plan. London: Department of Health. Department of Health (2001). National Framework for Older People. London: Department of Health. Department of Health (2002). Guidance on Single Assessment Process Dh HSC2002/001: LAC(2002)1. London: Department of Health. Department of Health (2004a). The National Quality and Outcomes Framework (QOF). London: Department of Health. Department of Health (2004b). The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process. London: Department of Health. Department of Health (2005). Supporting People with Long-term Conditions: An NHS and Social Care Model to Support Local Innovation and Integration. London: Department of Health. Department of Health (2006). Caring for People with Long-term Conditions: An Educational Framework for Community Matrons and Case Managers. London: Department of Health. Department of Health (2007). Raising the Profile of Long-term Conditions Care: A Compendium of Information. London: Department of Health. Department of Health (2010a). Equity and Excellence: Liberating the NHS. London: Department of Health. Department of Health (2010b). Healthy Lives, Healthy People. Our Strategy for Public Health in England. London: Department of Health. Department of Health (2011). Operating Framework for the NHS in England. London: Department of Health. Department of Health, Social Services and Public Safety (2002). Investing for Health. Belfast: The Irish Government. Horton, K. (2008). The use of telecare for people with chronic obstructive airways disease. Implications for management. Journal of Nursing Management, 16(2), 173–180. National Health Service Direct (2010). Facts and Figures, Available at: http://www.nhsdirect. nhs.uk/News/FactsAndFigures (accessed April 2011). NHS Direct (2011). History. Available at: http://www.nhsdirect.nhs.uk/en/About/History (accessed April 2011). NHS Scotland (2007). Better Health, Better Care. Edinburgh: The Scottish Government. NHS Scotland (2010). The Healthcare Quality Strategy for NHS Scotland. Edinburgh: The Scottish Government. Nolan, M. and Caldock, K. (1996). Assessment: Identifying the barriers to good practice. Health and Social Care in the Community 4(2), 77–85. Nursing and Midwifery Council (2005). Implementation of a Framework for the Standards of Post-registration Nursing: Agendum 27.1. C/05/160. London: NMC.
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Sue Lillyman and Ann Saxon Pharmaceutical Services Negotiating Committee (2004). The New NHS Community Pharmacy Service. London: PSNC. Pharmaceutical Services Negotiating Committee, Department of Health and NHS Primary Care Contracting (2006). The New Community Pharmacy Contractual Framework. How a Collaborative Approach will Benefit Patients, GPs and PCTs. Available at: www.psnc.or.uk/ data/files/Pharmacycontract/Information_for_GPs/messages_for_gps_september_2006.pdf (accessed April 2011). Puttick, H. (2011). How television could save the lives of Scotland’s 40-something couch potatoes – Case study. The Herald/Sunday Herald 20 February 2011. Royal College of Nursing (2005). Guidance for Nurses and Managers in Creating KSF Outlines. London: RCN. Social Care Institute of Excellence (2008). Personalisation: A Rough Guide. London: SCIE. Stewart, J. (2008). Report for the Ministers of Health, England and Wales. Digital Interactive TV (DITS) in the UK. Available at: http://www.homepages.ed.ac.uk/jkstew/work/interactive_ digital_TV-_in_uk.pdf (accessed April 2011). Swann, J. (2005). The single assessment process: An overview. Nursing and Residential Care 7(92), 84–86. Welsh Assembly (2010). Our Healthy Future. Cardiff: The Welsh Assembly.
Useful web resources Department of Health (support for people with long-term conditions to self-care and guide to developing local strategies and good practice) www.dh.gov.uk
NHS End-of-Life Care Programme www.endoflifecareforadults.nhs.uk
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Chapter 3
Assessment of patients with long-term conditions Sue Lillyman
Key areas Care pathways and care plans Types of assessment and models Quality of life indicators
Introduction In order to care for a patient within a hospital or community-care setting the professional will need to assess the patient in order to develop a care package that is tailored to each individual. This assessment results in a care plan that might consist of one or more health and/or social care services. It may also include community-based care or residential long-term care. The package can be fully funded for health and social care, health and/or social care, rehabilitation services, or entry to a long-term care facility. The assessment for any care package is based on local strategic health authority (SHA) criteria and allows the professional to make appropriate judgements regarding an individual patient.
Nursing assessments The nursing assessment is different from the medical examination in that its purpose is to collate both subjective and objective data from the patient and their carer (see Table 3.1).
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Sue Lillyman Table 3.1 Examples of objective and subjective data
Objective data
Subjective data
Objective data is collected during an assessment and is usually based on observations and physical assessment. It may include:
Subjective data is what the patient says or feels. It may include: Comments the patient makes about the history of their illness
Observed behaviour (e.g. in relation to activity, pain, gait)
What symptoms or sensations they are feeling
Measurements (e.g. temperature, pulse and blood pressure)
How it affects their mental state and well-being
Laboratory and other test results
Their beliefs, ideas, values and personal information about their condition
Skin, eye or lip colour Physical symptoms (e.g. oedema, shortness of breath) Sounds heard from percussion or listening to patient What is felt from palpation of abdomen
A useful tool for collecting subjective data is the SF-36 Health Survey that has been found helpful in the care planning for people with long-term conditions such as chronic obstructive pulmonary disease (Bentsen et al., 2008) and osteoarthritis (Pollard et al., 2007).
An example of the questionnaire can be obtained from: http://www.anapsid.org/cnd/files/sf36.pdf . It is important to note that both subjective and objective data are equally important and must be assessed together if an appropriate package of care is to be developed. Data and information are collected and recorded to determine the patient’s overall functioning in order to make a professional clinical judgement as to the care and support required by the patient based on the local SHA criteria. This may involve a care plan enabling the patient to return to health or, when the patient has one or more complex long-term conditions, to assist the patient to gain a suitable quality of life so they can be as independent as possible.
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Assessment of patients with long-term conditions The process involves gathering information about the health status of the patient including the social, psychological, economical, physical and spiritual aspects, all of which might have a potential impact on the care package that is provided. Once the information is gathered, the process of analysing and synthesising it is completed by the healthcare professional in order to make judgements about the type of intervention that is required for that particular patient. Patients who are then deemed capable of self-care might only require minimal input from the healthcare professional, such as reviews of medication and health checks. However the patient presenting with complex long-term conditions may require maximum support in the home environment or hospital care, whichever is judged to be the more appropriate setting for both the patient and carer.
The Royal College of Nursing have produced a guide to fully funded NHS care (Royal College of Nursing, 2006) and further information can be found at the NHS Choices web page at: http://www.nhs.uk/CarersDirect/guide/practicalsupport/Pages Financialhelpwithsupport.aspx.
Case Study 3.1 You are asked by a GP to visit a 65-year-old lady, Mrs M, who lives alone in a one-storey, semi-detached house in the middle of the city. On entering the house you are greeted by her daughter who is visiting at the time. The house is well kept and clean and Mrs M looks well cared for. On entering the living room Mrs M is unable to get up from her chair and she appears to be short of breath when she tries to talk. Her fingernails are blue and her cheeks are a high red colour. She uses her accessory muscles to breath even when sitting in the chair. She has difficulty talking and her hearing seems a little impaired. She states she has felt unwell for the last year but has got worse these last few weeks, and mentions that she is unable to climb the stairs so she sleeps in her armchair. When she lies down she tells you she has difficulty breathing and cannot get up again.
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Sue Lillyman You take her blood pressure which is 140/95 mmHg, her pulse is 85 beats per minute, her oral temperature registers 38°C and her respirations at 16 per minute. She tells you she lives alone but her daughter lives nearby and visits daily to prepare her food, provide her drinks and help her to the toilet. The daughter also helps her mother get washed and dressed every day. Mrs M has not visited her doctor for several months as she states she has been unable to get there and does not want to call him out, although lately has been feeling very ill and her daughter had insisted that she was visited now. She has been taking some pain-killers for the pain in her knees and salbutamol for some time for her wheeze. She states she used to smoke but cannot any more due to her immobility and she feels constantly tired. She has a cough and the sputum is clear. You notice her ankles are swollen and she appears to have lost weight as her clothes are big on her.
Exercise 3.1 List some of the objective data you have noted during your assessment of Case Study 3.1. Now list some subjective data about it. What other information would you want to find out in order to develop a care pathway for Mrs M?
Integrated care pathways Once an assessment is completed, a specific care pathway can be developed. These are usually based on nationally agreed guidelines, standards and protocols incorporating best practice and evidence-based guidelines for a given condition. They detail the essential steps for a patient’s journey with a specific condition or problem and describe the expected outcome for that patient (Campbell et al., 1998). They can be in the form of algorithms or a flow chart
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Assessment of patients with long-term conditions and can help with the coordination of care, providing timelines and categories of care and activities to be used by all members of the multidisciplinary team, with a focus on quality (Hill, 1998).
More information in relation to integrated care pathways can be found at: http://www.openclinical.org/clinicalpathways.html.
A guide for policy-makers and examples of integrated care pathways can be found at: http://www.ilcuk.org.uk/files/pdf_pdf_7.pdf.
For a toolkit for mental health integrated care pathways see: http://www.icptoolkit.org/.
Personalised care plan From the assessment, a personalised care plan should be developed that includes the lifestyle and personal strengths of the patient. This should include their abilities to cope with their condition, and their interests and wishes. When developing these plans, consent should be obtained to share the care plan with other members of the care team and a review date should be set.
Types of assessment Assessment is not a one-off activity by the healthcare professional when we first meet the patient, but an ongoing process. Each encounter or visit with the patient will require some assessment in relation to changes in their condition, changes in their personal goals and/or quality of life requirements. Other types of assessment include: • Initial assessment. • Ongoing or partial assessment. • Focused or problem-orientated assessment. • Emergency assessment. Each assessment will vary in the amount and type of data collected from the patient or carer or family member. To assist the practitioner, many models of health assessment have been developed over the years and each will
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Sue Lillyman determine the approach the healthcare professional takes and how they and the patient set realistic goals. All the initial assessment models described below are based on methodological processes. These processes include the initial assessment, which will assist the healthcare professional in their diagnosis of needs, condition and care. Depending on the model chosen, the practitioner can then plan the care, set nursing and healthcare goals. During the implementation of any care package there also needs to be a continual process of evaluation and assessment to identify changes in the patient’s conditions or circumstances. Assessment is not just a matter of physical observation, physical examination and history taking, but it must cover other factors such as those identified by Crouch et al. (2005), including ethical aspects and gaining consent, respect for the person, privacy, confidentiality, respect for dignity and truthfulness with the patient. They also note the importance of the environment, health status, age, cognitive ability of the patient, any learning disability and health assessments that need to be considered at this stage of gathering information and assessing the patient’s needs. To assist the practitioner in collecting the relevant data and forming their initial assessment, there are a variety of models developed including the following overall assessment models: • Deliberative Nursing Process (Orlando, 1961). • Maslow’s Hierarchy of Needs (Maslow, 1943). • Single Assessment Process (Department of Health, 2001). • Health-promoting Self-care System (Simmons (1990). • Self-care Framework (Orem, 1985). • Roy’s Adaptation Model (Roy, 1984). • Activities of Daily Living (Roper et al., 1980). • Health Care Systems Model (Neuman, 1980). • Conceptual Model (King, 2006). • Neighbours’ Consultation Model (Neighbours, 1987). • Pendleton’s Consultation Model (Pendleton et al., 2003). For more specific areas of assessments that can be used for patients with long-term conditions there are quality of life indicators, such as: • The Short Form 36 (SF-36) (Ware and Sherbourne, 1992). • The Nottingham Health Profile (Nouri and Lincoln, 1987).
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Assessment of patients with long-term conditions There are also a host of specific assessment tools that focus on specific areas of care, such as: • Continence assessment (see http://www.bladder.com.au/pdf/ DailyBladderChart.pdf for a daily bladder chart). • STRATIFY falls assessment (Oliver et al., 1997). • Malnutrition Universal Screening Tool (MUST) (Malnutrition Advisory Group, 2003). • Waterlow’s Tissue Vitality Score (Waterlow, 1985). • Mental Health Status (Mini Mental Health Test) (Folstein et al., 1975). • Unified Parkinson’s Disease Rating Scale (Fahn et al., 1987). • NIHSS Stroke Scale (Brott et al., 1989). This list is not exhaustive and you will find many others in the healthcare literature. Whichever model is chosen for assessing the patient with long-term conditions it is important that a multidisciplinary and multi-agency approach is included to prevent the patient having to undergo repeated assessments for the same information.
The Long-Term Conditions (LTC) Delivery Support Team website provides access to local groups and self-assessment tools. You can find this at: http://www.ltc-community.org.uk. Some of the assessment models noted above are described below.
Nursing process This was developed in the USA by Ida Jean Orlando (Pelletier) and in 1958 she published her first book The Dynamic Nurse–Patient Relationship: Function, Process and Principles of Professional Nursing Practice (Marriner et al., 1989). In 1972 she went on to write her book The Discipline and Teaching of Nursing Processes. Her theory emphasised the reciprocal relationship between the patient and the nurse and moved the nurse to develop logical thinking rather than conforming to medical orders. Today the nursing process is widely acknowledged and used within the UK. It is based on a cyclical approach of health assessment, nursing diagnosis, care planning, implementation of the care plan and evaluation of the care. It is a problem-solving and deductive theory, with a patient-centred, goalorientated approach. The nurse uses various tools, such as a holistic nursing framework or model, to facilitate the process of assessment.
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The assessment stage requires the nurse to gather data about the patient as an individual and their health; it explores what influences their health. The nurse then analyses the assessment data. Social problems are also noted, and any emerging problems associated with the assessments. Actual problems and potential problems are also collected and recorded. At this stage the assessor needs to include the biological, psychological, social, cultural and spiritual influences in a holistic approach that is advocated within this model. Other models such as Orem’s self-care (1985), Roper et al.’s activities of daily living (1980) and others may also be used for data collection. The healthcare professional can then set realistic goals with the patient that are measurable, attainable and understandable by the patient and carer.
For further information please visit: http://currentnursing.com/nursing_theory/application_nursing_theories.html.
Maslow’s hierarchy of needs Maslow based his model on a hierarchy of needs (Maslow, 1943) where he developed his pyramid working up from the most fundamental of human needs to what he referred to as the level of ‘self actualisation’. Although it is commonly used for measuring motivational drive it can be adapted for overall human well-being. He used a pyramid approach where he identified an order of importance through five levels of needs from physiological, through safety, love/belonging, esteem to self actualisation at the top. His theory is that people need to work through these levels and when an area is deprived in their lives then the patient will need assistance to repair that before they can move upwards.
The health-promoting self-care system This model was developed by Simmons in 1990 in an effort to theoretically integrate self-care and health promotion. It was based on a synthesis of elements of the self-care deficit-nursing model, the interaction model of client health behaviour and the health promotion model.
Orem’s model Dorothea Orem developed her model in the USA in 1985 and based her assessment on the self-care model. She noted that all patients have self-care needs and it is their right to meet those themselves when possible. When a patient becomes ill, she suggested, there is a deviation of self-care requisites
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Assessment of patients with long-term conditions which will require a change in their behaviour. The self-care deficit only requires intervention when the patient is not capable of meeting the demands of the illness or disease. For further information read Steven Cavanagh’s book Orem’s Model in Action (Cavanagh, 1991) and Donna Hartweg’s book Dorothea Orem: Self-Care Deficit Theory (Hartweg, 1991).
For further information and research on this model visit: http://currentnursing.com/nursing_theory/self_care_deficit_theory.html.
Exercise 3.2 Assess the scenario in Case Study 3.1 using Orem’s model under the following headings: Self-care Support of life processes Prevention and control of disease Prevention or compensation for disability Promotion of well-being Maintenance of sufficient intake of air Maintenance of sufficient intake of water Maintenance of sufficient intake of food Satisfactory elimination functions Balance between activity and rest Balance between solitude and integration Prevention of hazards to life Promotion of functioning within social groups Roy’s Adaptation Model Sister Callista Roy developed her model in the 1960s in California. This model is based on a systems theory and assesses the way in which a person, as a
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whole system, responds or adapts to internal or external changes or stimuli. She incorporates a problem-solving approach with goal-setting, planning, implementing and evaluating care. She advocates a person-centred approach to care, where goals are set with the patient to help them adapt to the stimuli by changing their behaviour whenever possible.
For more information on this model please visit: http://currentnursing.com/nursing_theory/Roy_adaptation_model.html.
Exercise 3.3 Assess and plan the care for Mrs M in Case Study 3.1 using the following aspects of Roy’s model: Physiological mode (meeting basic needs). Self-concept mode (the ability to meet goals taking into account personal values). Role of mastery/function system (determine the roles of the carer and/or family). Interdependency system (determine how independent the patient is).
Activities of Daily Living (Roper et al., 1990) Roper and her colleagues were the first to develop a nursing model within the UK (Roper et al., 1980) and this one is now widely used with the NHS. They based it on the fourteen activities of daily living, derived from a modification of Virginia Henderson’s Concept of Nursing (Henderson, 1966). The activities all have three components, namely physical (physiological), social and psychological. The goals of this model are to assist the individual by providing suitable conditions for him or her to perform unaided, using an approach that aims to restore the individual to maximum independence in their activities of daily living and enabling them to cope (with dependence on others, if necessary). The model also includes preventive activities and strategies to promote recovery and lead to independence wherever possible. They base
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Assessment of patients with long-term conditions their approach on life-span and a dependence–independence continuum, and how a person’s position can change with a range of age-related, environmental or illness factors. The model also identifies what they refer to as three types of activities: preventing activities, comforting activities and seeking activities. These include seeking out new knowledge. When the patient is unable to be independent in any of the activities then nursing is required to assist him or her back to eventual independence or supported care. Further information can be found in Holland et al.’s book Applying the Roper–Logan–Tierney Model in Practice (Holland et al., 2008).
Exercise 3.4 Plan the care for Mrs M in Case Study 3.1 using the following aspects of Roper et al.’s model: Safe environment Communication Breathing Elimination Washing and dressing Controlling temperature Mobilisation Working and playing Expressing sexuality Sleeping Death and dying
Health Care Systems Model (Neuman, 1980) This approach was developed in the USA by Betty Neuman (1972) at a time when nursing was moving away from the traditional illness model to a holistic approach, with the emphasis on prevention, health education and wellness. It
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Sue Lillyman incorporated an interdisciplinary approach to care management. It is based on the equilibrium of a balanced life, in which problems arise and cause tensions that disrupt that equilibrium. During such episodes the stress stimulus (stressor) causes tension and we can interact with the environment to adapt or change. Intervention is only enacted when the patient cannot adapt to the stressor and requires help to build their coping mechanisms. Data is collected at the assessment stage in relation to biographical and physiological stressors from the patient’s perceptions and stressors from the nurse’s perspective. The model comprises five interrelated variables covering physiological, psychological, sociocultural and spiritual domains. These are reviewed by the nurse to establish a baseline for each aspect, in order to gain a nursing diagnosis prior to setting goals and evaluating their outcomes with the patient.
For further information and example of this model visit: http://currentnursing.com/nursing_theory/application_Betty_Neuman’s_model.html.
Neighbours’ Consultation Model (Neighbours, 1987) This model, and Pendleton’s model that follows, was designed for use in the doctor’s consultation, but it can also be used in the assessment of people with long-term conditions. Neighbours’ model is an inner consultation model, that relates to specific areas for ‘safe doctoring’. Its approach to assessment was developed with GPs in mind, rather than nurses. It involves building good rapport between the GP and the patient. The consultation is viewed as a vulnerable environment for the doctor, and the emphasis is on the patient and doctor working together to negotiate management care plans. Mutual respect and collaboration are important factors, whereby achievable goals are set for the patient. The model revolves around five consultation tasks, including: • Connecting and establishing a rapport with the patient. • Summarising, in order to discover the patient’s ideas, concerns and expectations. • Handover, whereby the doctor and patient agree agendas through negotiation. • Safety netting, whereby a contingency plan is made in case things do not go according to plan. • Housekeeping, and making sure that the doctor is ready for the next patient.
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Assessment of patients with long-term conditions Pendleton et al.’s Consultation Model (Pendleton et al., 1984) This model was also designed for the doctor’s consultation. Its approach assumes that the consultation is effective when it is patient-centred, and the model is divided into seven tasks to achieve this: • Defining the reason for the patient’s attendance (this takes into account history-taking, aetiology, patient’s ideas, anxieties and expectations, and the effects of the problem on their quality of life). • Considering related problems, such as continuing problems, and (at the same time) reviewing any risk factors affecting the patient. • Choosing appropriate action. • Developing a shared understanding of the problems with the patient. • Involving the patient in their own management and encouraging them to accept appropriate responsibility. • Making appropriate use of time and resources. • Establishing and maintaining positive relationships with the patients and helping them to achieve any other tasks. This approach emhasises self-management, patient empowerment and relies on partnership working between the patient and the professional (Harper and Ajao, 2008).
Other theories We have concentrated on some of the more widely used models within the UK although Fawcett and Swoyer (2005) note that other models are constantly being added to the list, such as Johnson’s Behavioural Systems Model (1990), Levine’s Conservation Model (1990), Roger’s Science of Unitary Human Beings (1990) and Leininger’s Theory of Cultural Care Diversity and Universality (Leininger and McFarland, 2006). More specific models exist for use in mental health situations, such as Peplau (1992) and Barker (2001), for people with learning disabilities, such as the Ecology of Health Model (Aldridge, 2003). For older people, the EshunSmith model (1999) can be used. King’s Conceptual Model (2006) concentrates on the continuing ability of patients to meet their basic needs and to function in their socially defined roles.
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Quality of life indicators The Short Form 36 (SF-36) (Ware and Sherbourne, 1992) Ware and Sherbourne developed this health survey in 1992 in the US. It was designed to provide assessments that are not age specific, disease specific, or treatment group specific. It included 36 items that covered eight health concepts, namely pain, physical functioning, role limitation due to physical and/or emotional or mental health problems, mental health, vitality, social functioning and general health. Following a scoring process, the healthcare provider is able to show the responsiveness to changes in health status over time. Gupta (2008) suggests that this model is general in nature and not suitable for the assessment of disability and has limited coverage of the activities of daily living.
Nottingham Health Profile (Nouri and Lincoln, 1987) This profile was developed mainly for epidemiological studies of health and disease. It consists of two parts, in which the first part reviews six dimensions including pain, physical mobility, emotional reactions, social isolation and sleep. The second part relates to the problems of daily living. Nouri and Lincoln also produced the Nottingham Extended Activities of Daily Living questionnaire, which is used to assess the mobility of the patient. However, Gupta (2008) suggests that this focuses on what the patient has done rather than what the patient can do.
Conclusion Healthcare professionals can choose any of the above models, or others found in the literature, for assessing patients with long-term conditions. A holistic, systematic approach must be used, that includes the patient, the professional and, where appropriate, their carer or family member. These patients do not recover from their long-term conditions so they have to learn to adapt and live with them. It is up to the professional to assist them in whatever way they can to help them live as independently as possible and with the best quality of life.
References and further reading Aggleton, P. and Chalmers, H. (2000). Nursing Models and Nursing Practice, 2nd edn. London: Palgrave Macmillan. Aldridge, J. (2003).The ecology of health model. In: M. Jukes and M. Bollard. (eds) Contemporary Learning Disability Practice. Dinton: Quay Books.
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Assessment of the patient with long-term conditions Barker, P. (2001). The tidal model: Developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric and Mental Health Nursing 8(3), 233–240. Barrett, D., Wilson, B. and Woodlands, A. (2008). Care Planning: A Guide for Nursing. London: Pearson. Bentsen, S., Henriksen, A., Wentzel-Larsen, T. et al. (2008). What determines subjective health status in patients with chronic obstructive pulmonary disease: Importance of symptoms in subjective health status of chronic obstructive pulmonary disease patients. Health and Quality of Life Outcomes 6, 115. Brott, T., Adams, H.P., Olinger, C.P. et al. (1989). Measurements of acute cerebral infarction: A clinical examination scale. Stroke 20, 864–870. Campbell, H., Hotchkis, R., Bradshaw, W. et al. (1998). Integrated care pathways. British Medical Journal 316(7125), 133–137. Cavanagh, S. (1991). Orem’s Model in Action. London: Palgrave. Crouch, A., Rumbold, G., Thompson, M. and Turner, W. (2005). Factors to consider when assessing patients. In: A. Crouch and C. Meurier (eds) Health Assessment. Oxford: Blackwell Publishing. Department of Health (2001). NSF for Older People. London: Department of Health. Eshun-Smith, A.B. (1999). Effective rehabilitation for older people. Nursing Standard 13(40), 39–43. Fahn, S., Elton, R.L. and members of the UPDRS Development Committee (1987). Unified Parkinson’s disease rating scale. In: S. Fahn, C.D. Marsden, D.B. Calne, and M. Goldstein (eds) Recent Developments in Parkinson’s Disease. 2. New Jersey: Florham Park. Fawcett, J. and Swoyer, B. (2005). Evolution and use of formal nursing knowledge. In: J. Fawcett (ed) Contemporary Nursing Knowledge: An Analysis of Nursing Models and Theories, 2nd edn. Philadelphia: FA Davis. Folstein, M.F., Folstein, S.E., and Mc Hugh, P.R. (1975). Mini mental state: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 12, 189–198. Gupta, G. (2008). Measurement Scales used in Elderly Care. Oxford: Radcliffe Publishing. Harper, C. and Ajao, A. (2008). Assessment of a patient with a long-term condition using Pendleton’s Consultation Model. In: S. Lillyman and A. Saxon. Community Matrons: Caring for People with Long-term Conditions. Dinton: Mark Allen. Hartweg, D. (1991). Dorothea Orem: Self-Care Deficit Theory. London: Sage. Henderson, V. (1966). The Nature of Nursing: A Definition and its Implications for Practice, Research and Education. New York: Macmillan. Holland, K., Jenkins, J., Solomon, J, and Whittam, S. (2008). Applying the Roper–Logan– Tierney Model in Practice, 2nd edn. London: Churchill Livingston. Johnson, D. (1990). The behavioural system model for nurses. In: M. Parker (ed.) (1990) Nursing Theories in Practice. New York: National League for Nurses, pp. 23–32. King, I, M. (2006). Part one: Imogene King’s theory of goal attainment. In: M.E. Parker (ed.) Nursing Theories and Nursing Practice, 2nd edn. Philadelphia: FA Davis.
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Sue Lillyman Leininger, M.M. and McFarland, M.R. (2006). Culture, Care, Diversity and Universality: A Worldwide Nursing Theory, 2nd edn. Boston: Jones and Bartlett. Levine, M. (1990) Levine’s conservation model. In: M. Parker (ed.) Nursing Theories in Practice. New York: National League for Nurses, pp. 189–240. Malnutrition Advisory Group (2003). Malnutrition Universal Screening Tool. Available at; www. bapen.org/must_tool.htlm (accessed April 2011). Marriner, A. (1989). Nursing Theorists and their Work CV. St Louis: Mosby. Maslow, A.H. (1943). A theory of human motivation. Psychology Review 50, 370–396. Neighbour, R. (1987). The Inner Consultation: How to develop an effective and intuitive consulting style. Lancaster: Kluwer Academics Publishers. Neuman, B. (1980). The Betty Neuman Healthcare Systems Model: A total person approach to patient problems. In: J.P. Riehl and C. Roy (eds) Conceptual Models for Nursing Practice. Connecticut: Appleton-Century-Crofts. Nouri, F.M. and Lincoln, N.B. (1987). An extended activities of daily living scale for stroke patients. Clinical Rehabilitation 1, 301–305. Oliver, D., Britton, M., Seed, P., et al. (1997). Development and evaluation of the evidencebased risk assessment tool (STRTIFY) to predict which elderly inpatients will fall. British Medical Journal 7, 1049–1053. Orlando, I, J. (1961). The Dynamic Nurse–Patient Relationship: Function, Process and Principles. New York: GP Putman. Orem, D.E. (1985). Nursing Concepts of Practice, 3rd edn. New York: McGraw- Hill. Pendleton, D., Schofield, T., Tate, P., et al. (2003). The New Consultation: Developing Doctor– Patient Communication. Oxford: Oxford University Press. Peplau, H.E. (1992). Interpersonal relations: A theoretical framework for application in nursing practice. Nursing Science Quarterly 5, 13–18. Pollard, B., Johnston, M. and Dixon, D. (2007). Theoretical framework and methodological development of common subjective health outcome measures in osteoarthritis: A critical review. Health and Quality of Life Outcomes 5, 14. Rogers, M. (1990). Martha Rogers’ theoretical framework for nursing. In: M. Parker (ed.) Nursing Theories in Practice. New York: National League for Nurses, pp. 105–128. Roper, N., Logan, W. and Tierney, A. (1980). The Elements of Nursing Based on a Model of Living, 3rd edn. Edinburgh: Churchill Livingstone. Roy, C. (1984). Introduction to Nursing: An Adaptation Model, 2nd edn. New Jersey: Englewood Cliffs. Royal College of Nursing (2006). Guide to Fully Funded NHS Care. London: Royal College of Nursing. Simmons, S.J. (1990). The Health Promoting Self Care System Model: Directions for nursing research practice. Journal of Advanced Nursing 15: 1162–1166. Ware, J.E., and Sherbourne, D. (1992). The MOS 36 item Short-Form Health Survey (SF-36). Medical Care 30, 473–483. Waterlow, J. (1985). A risk assessment card. Nursing Times 81, 49–55.
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Useful web resources Nursing Theories (companion to nursing theories and models such as Betty Neuman’s model and Roy’s adaptation model) www.currentnursing.com
NHS Choices (with practical support for carers in the Carers Direct section) www.nhs.uk
Open Clinical (information on clinical pathways) ww.openclinical.org
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Chapter 4
History-taking and assessment Ann Saxon
Key areas Healthcare needs and needs assessment History-taking and structure Patient interviews and interview skills Models of consultation
Introduction The World Health Organization’s definition of health is ‘Health is a state of complete physical, psychological, and social wellbeing and not simply the absence of disease or infirmity’ (World Health Organization, 1948). This definition has not been revised since, and it provides us with an opportunity to note that health is not just a state of bodily function or dysfunction, but takes into account the whole person. Person-centred care is essential for long-term conditions care because the patient is not only suffering the pathophysiological progress of a disease but also psychological and quality of life issues. Quite often, a person suffering with a long-term condition has complex needs and multiple symptoms. In supporting these patients, therefore, it is essential that practitioners are aware of the wider perspective rather than just the physical domains.
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Healthcare needs Needs assessment is an essential requirement of good primary care facilities. It encourages a wider focus of establishing need than that just of a physical domain. Healthcare needs can be identified as those that can benefit from: • Health education. • Disease prevention. • Diagnosis. • Treatment. • Rehabilitation. • Terminal care. When identifying the healthcare need, healthcare professionals should have the skills required to work through any of the above areas in providing a package of care for patients with long-term conditions. Dahlgren and Whitehead (1991) identified the wider social and environmental determinants of health that contribute to a person experiencing a poor health state. They discuss the main determinants of health as: • Individual lifestyle factors, such as age and sex. • Constitutional factors. • Social and community networks. • General socioeconomic, cultural and environmental factors, such as agriculture and food production, education, housing, healthcare services, work environment, employment and sanitation. Further information can be obtained from the Acheson report (Acheson, 1998). They suggest that most of the factors listed above can be affected by individual, commercial and political decisions.
Health needs assessment Health needs assessment is the systematic collection of subjective data and objective data, used to determine a client or patient’s functional health status. It is recognised that practitioners collecting this data will use a range of senses including sight, smell, listening and touch (Grossman, 1999).
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History-taking and assessment
Principles of history-taking History-taking is a key component of making an assessment and diagnosis, and it enables the practitioner to gain insights into how and why the patient may be presenting with the signs and symptoms of a particular disease or illness. It takes a great deal of practice to become confident and stay focused on history-taking skills, and the skills required will develop over time. It is important for the practitioner to recognise that the history-taking episode can be affected by any of the factors listed in Exercise 4.1, therefore a systematic approach should be adopted.
Exercise 4.1 Consider some of the common problems associated with history-taking: Clinician taking over Patient cannot answer – memory problems Language or sensory/physical difficulties Embarrassment Inability to focus patient’s response Closed questions Failure to seek clarification Emphasis on a few problems Lack of logical timeline recording of illness Initial interview It is usual for the initial interview to follow a sequential pattern for obtaining good quality assessment data, with several distinct phases. Introductory phase: • Introduction of self. • Explanation about note-taking. • Types of questions to be asked. • Ensure comfort and privacy.
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Ann Saxon Working phase: • Facilitate client’s comments and elicit biographical data. • Establish reason for seeking health care. • Listen and observe. • Collaborate with the client to identify problems and goals. • Facilitation may be free flowing or structured, depending on the time and information needed. Summary and closure phase: • Summarise information from the working phase. • Agree plans with client to resolve the problems. Consultation is much like an initial interview except that you are moving towards not only assessing but also making some sort of diagnosis, and prescribing some form of treatment.
Exercise 4.2 List some of the differences between carrying out an initial interview and a consultation. What extra skills might you require for a consultation to take place?
Planning is an essential skill in history-taking and, as previously mentioned, your skills will develop over time with different patients and clients. This section will now look at using a consultation approach. The general structure of the consultation involves: • Greeting the patient. • Discovering the problem. • Making an assessment. • Agreeing the nature of the problem. • Agreeing a possible solution and possible diagnosis. • Ending the consultation.
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History-taking and assessment
Case Study 4.1 Mr X is an 85-year-old gentleman who presents at your clinic with a history of chronic obstructive pulmonary disease for the past 5 years. He has had several hospital admissions for his condition. He has difficulty walking, and he appears breathless and has a noticeable wheeze.
Exercise 4.3 Draw on your verbal and non-verbal skills to explain what factors you would consider in your initial assessment of Mr X from Case Study 4.1.
Factors that can affect the interview stage There are some factors that influence how successful you are in conducting your consultation, among which are: • Self awareness. • Environmental factors. • Personal space. • Personal appearance. • Other non-verbal communications. It is important that you have given some consideration to all of these factors because they may influence how successful your interview is. Choosing the right environment to ensure privacy and dignity is essential, and you should ensure that you will not be interrupted during the interview.
Interview skills The skilled interviewer is one who demonstrates: • Active listening (without drifting off on to other subjects). • Adaptive questioning (encouraging the patient to add details where appropriate). • Directed questioning.
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Ann Saxon • Questioning that elicits a graded response. • Questioning by asking a series of questions (one at a time – not multiple questions). • The ability to offer multiple choices for answers. • The ability to clarify what the patient means by summarising and reflecting. Interview techniques to avoid include: • Asking persistent questions when the client does not understand what is being asked or does not want to answer. • Using inappropriate language or jargon that might be misinterpreted. • Giving advice that will disempower the patient. • Giving false assurances, promises or hope. • Engaging in social chat when this is not productive or supportive.
Exercise 4.4 Consider how you may avoid the pitfalls in technique when interviewing a patient.
Below is a checklist of areas that need to be considered when organising a well-phrased history, and could be used as an aide-memoire for developing your history-taking skills. • Problem or presenting complaint. • History of presenting problem. • Relevant past medical history. • Allergies. • Essential family and social history. • Medications. • Systematic review of general health. • Head, eyes, ears, neck and throat (HEENT).
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History-taking and assessment • Cardiovascular system. • Respiratory system. • Gastrointestinal system. • Genitourinary system. • Musculoskeletal system. • Endocrine system. • Neurological system. • Mental health, anxiety and depression.
Heron’s six-category analysis model (Heron, 1986) This simple but comprehensive model was devised in the mid 1970s, initially for use in counselling and for the development of therapeutic integrity. It has also been used in nursing research as a theoretical framework and a model for clinical supervision (Sloane and Watson, 2002). It outlined the possible range of interventions a doctor or counsellor may use with a patient during a consultation, with interventions falling into six categories, each with a clear function within the consultation process. 1. Prescriptive (advising/telling). 2. Informative (instructive/interpreting). 3. Confronting (challenging/feeding back). 4. Cathartic (releasing emotions). 5. Catalytic (encouraging exploration). 6. Supportive (comforting/affirming).
Exercise 4.5 Reflect on a recent episode in which you used a consultation process with a patient or client. Use one or all of Heron’s six interventions to give examples of how they may be used.
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Ann Saxon The six-category model can be used at any stage of the consultation process, in particular when dealing with clients who have long-term conditions. For example, prescriptive might involved giving a patient advice on his or her technique with an inhaler, together with supporting information about how and when to administer it; confronting might entail exploring the reasons for medication non-compliance and the implications for the patient’s treatment.
Structured format of history-taking This collaborative model by Carroll (2007) uses elements from a multidisciplinary approach. The SOAPIE model is defined in Table 4.1. Table 4.1 The SOAPIE model
S Subjective data O Objective data A Assessment P Plan I
Implementation
E Evaluation The individual elements of SOAPIE can be broken down thus: Subjective data: This includes retrieving data from the patient’s perspective; what the patient says the problem is; what symptoms the patient says they are presenting with. Objective data: This includes what the practitioner observes; the findings of the physical examination; thorough direct questioning. Assessment: This includes a structured approach (as identified earlier in the chapter); a medical approach covering the presenting complaint and history of the presenting complaint, past medical history, medications and allergies, social and family history, and full physical assessment through inspection, palpation, percussion and auscultation (Longmore et al., 2001). Plan: This includes medicines management; self-management; referral for specialist treatment; immediate acute treatment; education; setting realistic goals. Implementation: This includes liaison with other members of the multidisciplinary team; carrying out planned care; resetting goals.
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History-taking and assessment Evaluation: This includes regular review of the care plan; revisiting goals. If the patient is complaining of pain, it is useful to use the acronym SOCRATES (Carroll, 2007) to assist in your assessment, as shown in Table 4.2. Table 4.2 The SOCRATES assessment
S Site of the pain O Onset and when the pain started C Character R Radiation A Associated features T Timing E Exacerbation or relieving factors (i.e. body position) S Severity on a scale of 1 to 10
Conclusion The message is to be systematic with which ever model you use. Always keep the patient informed, and document everything. Ensure that your plan includes evaluation and future planning to sustain treatment plans and to enable the patient to improve and remain stable. Always remember that patients with long-term conditions can become acutely ill very rapidly and this possibility needs to be taken into consideration during the planning stage.
References and further reading Acheson, D. (1998). Independent Inquiry into Inequalities in Health Report. London: Department of Health. Carroll, L. (2007). Acute Medicine. A Handbook for Nurse Practitioners. London: Wiley and Sons. Dahlgren, G. and Whitehead, M. (1991). Tackling inequalities in health: What can we learn from what has been tried? Cited in: World Health Organization (2006) European Strategies for Tackling Inequalities in Health: Levelling Up. Part 2. Denmark: WHO. Grossman, V.G.A. (1999). Quick Reference to Triage. London: Lippincott. Heron, J. (1986). Six-Category Intervention Analysis. Human Potential Research Group: University of Surrey. Longmore, M., Wilkinson, M. and Torok, E. (2001). Oxford Handbook of Clinical Medicine, 5th edn. Oxford: Oxford University Press.
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Ann Saxon Sloane, G. and Watson, H. (2002). Clinical supervision models for nursing: Structures, research and limitations. Nursing Standard 17(4), 41–46. World Health Organization (1948). Preamble to the constitution to the World Health Organization as adopted by the International Health Conference New York, 19–22 June 1946. Signed on the 22 July 1946 by representatives of 61 states (Official Records of the WHO No. 2) and entered into force on the 7 April 1948. Geneva: WHO.
Useful web resources Centre for Policy on Ageing (including training materials) www.cpa.org.uk
National Service Framework for Long-term Conditions (including guidelines on assessment) www.dh.gov.uk
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Chapter 5
Assessment of patients with chronic respiratory disease Ann Saxon and James Bethel
Key areas Patient interviews Causes of the presenting complaint (chronic obstructive pulmonary disease, emphysema, chronic bronchitis and asthma) Focused assessment and chest examination Lifestyle, quality of life, social and family factors Differential diagnosis Patient management and acute exacerbations
Introduction The global burden of disease has been shifting from acute communicable diseases to chronic illnesses, but unfortunately the systems designed to deliver treatment and care have not kept pace with this shift (World Health Organization, 2002). A significant rise has been noted in the number of people suffering from respiratory diseases and this has had an impact on the use of health service resources. The Department of Health (2005) identified that: • 80% of GP consultations are for chronic diseases. • Patients with chronic diseases use 60% of all hospital beds. • Two out of three medical emergencies admitted to hospital are for exacerbation of chronic disease.
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Ann Saxon and James Bethel • Chronic disease management accounts for approximately 78% of all healthcare spending. • Only about 50% of medication is taken as prescribed. This evidence suggests, among other things, that more and more people are living longer so that they develop chronic conditions and they are suffering for many years with chronic diseases. Respiratory diseases account for 6.5% of hospital admissions in the UK. In an emergency department with an annual attendance of 80,000 patients and a 20–25% admission rate, this accounts for between 1040 and 1300 admissions per year. The mean length of stay for patients with chronic obstructive pulmonary disease is 9.1 days. Asthma is the most common chronic disease in the UK (Royal College of Physicians, 2004). It is important when patients present with symptoms related to chest conditions that a focused assessment is carried out.
Patient interview The initial interview phase is important for helping to establish any underlying health problems and the severity of the illness the patient is currently presenting with. It is essential that emergency care and treatment is provided at this time, if required, and that any past medical history may have to be obtained from family and carers at a later date. This will enable you to commence a therapeutic relationship with the patient and help to put them at ease. It is also essential for the initial interview to be carried out with the patient in a comfortable upright position, preferably in quite a warm room. This will help put them at ease and allow for assessment to take place. If at any time the patient becomes distressed, then the assessment must cease and be recommenced at a more suitable time or when the patient has stabilised. The initial interview allows you to gather important information about the length and severity of the current problem and allows you to establish whether any previous chest conditions may be exacerbating at present. It is important to bear in mind the following six respiratory symptoms when carrying out your assessment: • Cough. • Sputum production. • Breathlessness.
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Assessment of patients with chronic respiratory disease • Chest pain. • Wheezing. • Haemoptysis.
A useful video in relation to the physical respiratory assessment can be found at: www.youtube.com/watch?v=WLxwayr20vY. You will be gathering information during the assessment that will enable you to draw up a plan of care in partnership with the patient and family or carer. You will need to consider your level of knowledge of the respiratory system and changes in the pathophysiology that maybe causing the patient’s current symptoms.
Exercise 5.1 Identify the structures on this diagram of the lungs. You can check your answers in an anatomy and physiology book or at www.patient.co.uk
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Case Study 5.1 Mr C is a 60-year-old who is presenting with difficulty in breathing. He smokes twenty cigarettes a day and has done so for most of his life. He has had a productive cough for the last five days and complains that he feels hot. He is feeling tired and reports that he can only walk a short distance without becoming breathless. Useful questions to ask In guiding the process of information gathering during the initial interview, you may want to ask some of the following questions: • Do you have a cough? What type of cough is it? • Are you producing any phlegm? What colour and consistency is the phlegm? • Are you short of breath? Does this occur with your normal daily activities? • Are you more breathless at night? • Do you smoke? For how many years? How many packs per day? • Do you have any allergies? • Are you taking any medication for your breathing? • Do you have a family history of tuberculosis or a chest condition? • Have you had an influenza vaccination? Gathering information like this will enable you to identify the cause or causes of the current problem, and will help in the clinical decision-making process.
Exercise 5.2 With reference to Case Study 5.1, list any other areas that would be of use to you in this initial assessment stage.
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Assessment of patients with chronic respiratory disease The initial assessment enables the practitioner to identify possible causes of the symptoms, in particular those that can be attributed to a specific disease process. Some of these will now be discussed in more detail.
Exploring causes of the presenting complaint Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease is characterised by airflow obstruction. The obstruction is usually progressive and it is not fully reversible. It does not change markedly over several months. The disease is predominantly caused by smoking (National Institute for Health and Clinical Excellence, 2004), with airflow obstruction arising due to a combination of airway and lung tissue damage (World Health Organization, 2006). For the clinical spectrum of chronic obstructive pulmonary disease, see Education for Health (2008).
Emphysema Where emphysema predominates, patients have relentlessly progressive breathlessness, unaccompanied by features of chronic bronchitis or asthma. The development of a barrel-shaped chest is a relatively early sign, and is often easily seen because these patients tend to be thin.
Chronic bronchitis Chronic bronchitis is defined by the production of sputum on most days, over a period of three months to two consecutive years, where other causes of sputum production are excluded.
Chronic longstanding asthma Some patients with a long history of asthma develop breathlessness and reduced lung function that does not fully reverse – even with maximum therapy. Spirometry is essential for establishing the diagnosis.
Scope of assessment and clinical examination Focused assessment Following on from the initial stage, a more focused assessment is required. This includes a full respiratory assessment. In developing your clinical assessment skills you may need to consider formal training and education, such as a diploma, a degree or some postgraduate studies.
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Ann Saxon and James Bethel Some education providers offer more detailed courses. For example, see: www.educationforhealth.org Part of your assessment may include a respiratory assessment tool such as the Medical Research Council Dyspnoea Scale (Education for Health, 2008). This scale was produced to enable breathless patients to assess their own level of performance, by covering a range of physical signs and symptoms: 1. Not troubled by breathlessness except on strenuous exercise. 2. Short of breath when hurrying on the level or walking up a slight hill. 3. Walks slower than people of the same age on the level because of breathlessness or has to stop for breath when walking at own pace. 4. Stops to get breath back after walking about 100 metres or after a few minutes on the level. 5. Too breathless to leave the house or breathless when dressing and undressing. The Borg Scale (Education for Health, 2008) has been used to measure the amount of breathlessness in patients (Kendrick, Baxi and Smith, 2000). It can be a useful tool to incorporate into your assessment process. A clinical examination should be carried out on the patient, and you may want to develop specific skills in the relevant areas.
Chest examination You should start by examining the anterior and posterior chest. The front side and rear view allows you to see any visible wounds, scars or lesions. Observe for symmetry of the chest wall. Then observe inspiration and expiration in terms of the rate and rhythm of breathing and the use of accessory muscles to aid breathing. Check for nasal flaring, the use of intercostal muscles, and pursed-lip breathing. These findings will help you to establish whether the patient has a chronic or longstanding respiratory condition such as emphysema or chronic obstructive pulmonary disease. Patients with chronic obstructive pulmonary disease may present with several of the above, and may lean forward to breathe or prop themselves up with their arms to assist breathing. It is important to carry out the following stages of a respiratory assessment, for which appropriate training and development is necessary. Practice over time is essential for enabling practitioners to make good judgements, and these
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Assessment of patients with chronic respiratory disease skills must be performed on a regular basis to ensure a level of competence. Inspection: a full visual inspection of the chest, including the colour and feel of the skin. Palpation: use touch to help gather information, for example during inspiration and expiration. Feel the neck and carotid area for any abnormalities (Fig. 5.1).
Figure 5.1 Chest Palpation Percussion: strike the chest to detect the presence of any underlying abnormalities, the amount of air in the lungs, and any fluid or solid mass (Fig. 5.2).
Figure 5.2 Chest Percussion
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Ann Saxon and James Bethel Auscultation: listen to the chest with a stethoscope to detect normal breath sounds or any unusual sounds.
Examples of breath sounds can be found at www.emsvillage.com/education.
Other investigations The normal range of clinical observations and investigations would also be carried out with a patient presenting respiratory problems. Among these are: • Temperature measurement. • Blood pressure measurement. • Pulse oximetry. • Spirometry. • Chest X-ray. • Blood profile. • Lung function tests.
Lifestyle and quality of life It is also useful to gather information in relation to the quality of life of patients with respiratory problems. As part of the assessment process some of the following questions may be asked: • What are the two daily activities that cause you the most breathlessness or distress? • What is your overall level of fatigue? • Are you upset or frightened by your episodes of breathlessness? • Do you feel in control of your breathlessness or fatigue? • Do you feel you are a burden to your family, friends or neighbours? • Do you feel it is safe for you to exercise? Other areas that could be covered may form part of the care pathway. The Activities of Daily Living model (Roper, Logan and Tierney, 1980; and see Chapter 3) addresses the following: • Breathing. • Eating and drinking. • Washing and dressing. • Mobility.
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Assessment of patients with chronic respiratory disease • Sexuality. • Death and dying. • Psychological state.
Social and family history In further developing the profile of the patient with respiratory problems it is appropriate to ascertain their family and social history as part of the assessment process. In obtaining a patient’s social history, you can ascertain whether any social aspects of their life have contributed to their current illness. For example, by determining their employment status and the type of job they are employed in, you can find out if they have they been exposed to any: • Fumes. • Hazards. • Tar or tar-containing substances. • Allergens (such as pollen). Leisure activities should also be explored as the patient may have been involved in certain activities that could have put them at risk. Obtaining a family history may help to establish if there is a genetic link or risk factor. For example, you might ask: • Has any family member recently had tuberculosis? • Does anyone in your family suffer with asthma or another long-term respiratory condition?
Exercise 5.3 Consider what type of job might carry a risk of respiratory problems. Consider what respiratory conditions might be hereditary.
Case Study 5.2 Mrs R is a 61-year-old woman with chronic obstructive pulmonary disease. When you first visit her, she complains of shortness of breath.
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Ann Saxon and James Bethel
Exercise 5.4 What specific questions will you ask during your consultation and history-taking with Mrs R from Case Study 5.2? What physical examination techniques might you utilise to enhance assessment? What specific pathology will you want to exclude (and how will you do this)? How will you make your decision to refer to her secondary care?
Differential diagnosis According to Education for Health (2008), other diagnoses you should also consider are: • Pneumonia. • Pneumothorax. • Left ventricular heart failure. • Pulmonary embolism. • Lung cancer. • Upper airway obstruction. • Pleural effusion.
Patient management Medications In considering the needs of a patient with respiratory problems it is worthwhile assessing their current medication. Check their use of: • Inhalers (and their technique). • Long-term oxygen therapy. • Steroids. • Antibiotics. • Other medications. An exacerbation of a respiratory condition is often triggered by inappropriate inhaler technique or because of missed medications.
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Assessment of patients with chronic respiratory disease Other areas to consider are: • Smoking status (and the desire to quit). • Exercise tolerance. • Attendance at a pulmonary rehabilitation clinic. • Symptom control. • The presence of depression.
Acute exacerbations of long-term respiratory conditions It is important to recognise an exacerbation of an existing respiratory condition, by looking for the following important signs and symptoms: • Worsening breathlessness. • Increase in sputum production. • Increased cough. • Chest tightness. • Exercise intolerance. All of the above signs may indicate that further investigations are required. It would also be of benefit to the patients and family if the treatment options were considered, including the possibilities of home care or hospital treatment.
Conclusion Assessment skills are an essential part of the care of patients with respiratory disorders and they may help you decide which plan of care is most appropriate. You may need to develop a range of skills – in particular those relating to physical examination of the respiratory system.
References and further reading Department of Health (2005). Supporting People with Long-term Conditions. London: Department of Health. Education for Health (2008). Simply COPD: A Practical Handbook, 5th edn. Warwick: Education for Health. Kendrick, K., Baxi, S. and Smith, R. (2000). Usefulness of the 0–10 modified Borg scale in assessing the degree of dyspnoea in patients with COPD and asthma. Journal of Emergency Nursing, 26(3), 216–222. National Institute for Health and Clinical Excellence (2004). Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care. London: NICE.
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Ann Saxon and James Bethel Roper, N., Logan, W. and Tierney, A. (1980). The Elements of Nursing. Edinburgh: Churchill Livingstone. Royal College of Physicians (2004). National Clinical Guideline on Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care. London: Royal College of Physicians. World Health Organization (2002). Global Burden of Disease in 2002. Data sources, methods and results. Geneva: WHO. World Health Organization (2006). Global Initiative for Chronic Obstructive Lung Disease. Available at: http://www.who.int/respiratory/copd/GOLD_WR_06.pdf (accessed April 2011). World Health Organization (2008). The Top Ten Causes of Death. Fact Sheet No. 310. Geneva: WHO.
Useful web resources British Lung Foundation www.lunguk.org
British Thoracic Society www.brit-thoracic.org.uk
Paper to Patient (interactive resource in relation to chronic obstructive pulmonary disease) www.papertopatient.co.uk
Smoking cessation www.quit.org.uk
Clinical Knowledge Summaries (care in the community) www.cks.nhs.uk
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Chapter 6
Assessment of patients with chronic heart failure Ann Saxon and Sue Lillyman
Key areas Epidemiology and aetiology of chronic heart failure Assessment and history-taking and models of consultation Symptoms, functional capacity and quality of life Clinical review and examination Patient management and lifestyle modification
Introduction Coronary heart disease is a major contributor to mortality and morbidity in the UK (Department of Health, 2007). The National Quality and Outcomes Framework (QOF) is the annual reward and incentive programme for general practice. For the years 2006–2007 it reported prevalence of a number of cardiovascular conditions in England: • 1.9 million with coronary heart disease. • 863,000 with stroke and transient ischaemic attack. • 900,000 with heart failure. The prevalence of these conditions varies across regions. It has been reported that many factors contribute to the disease trajectory of all three and no single factor has been established (Department of Health, 2007). According to a report by the World Health Organization (2008) on the ten leading causes of death, it is estimated that 12.2% of deaths worldwide are attributed to coronary heart disease, stroke and transient ischaemic attacks, which amounts to a total of
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Ann Saxon and Sue Lillyman 7.20 million deaths each year. The leading causes of heart failure are diseases that damage the heart. In many circumstances, patients with heart failure have had previous coronary heart disease, including high blood pressure and diabetes. This chapter will focus specifically on heart failure.
Epidemiology and aetiology of heart failure It is estimated that around 900,000 people in the UK have heart failure (National Institute for Health and Clinical Excellence, 2010) and as many again have failing hearts, but without symptoms (Petersen et al., 2002). Incidence increases with age, and the average age of first diagnosis is 76 years (Cowie et al., 1999). Numbers of people with the disease are expected to rise in parallel with the ageing population. It is estimated that 30–40% of patients die within one year of diagnosis, although the trend is improving as treatment and knowledge improve (Cowie et al., 1999). Around 2% of the adult population in the UK experience symptoms due to heart failure and it is one of the most common reasons for admission to hospital (Department of Health, 2000). It is the biggest single cause of premature death in the UK, being responsible for over 135,000 deaths per year. One in four men and one in five women die from the disease. Due to the nature and complexity of long-term conditions it is likely that many practitioners will care for patients who are experiencing some problems with heart failure. Many practitioners are faced with caring for patients with heart failure, both in secondary and primary care. It is important, therefore, to develop a range of assessment skills that enables the practitioner to perform a focused assessment in order to alleviate their patients’ symptoms and prevent worsening of the condition. As a chronic condition, heart failure has not attracted the same high profile as acute myocardial infarction (Pearson and Cowie, 2005), and changes in clinical practice have not taken place as quickly as they have for other diseases. It is, however, a major cause of ill health in patients with long-term conditions. According to the NICE guidelines (National Institute for Health and Clinical Excellence, 2010): • Heart failure accounts for a total of 1 million inpatient bed-days. • Heart failure accounts for 2% of all inpatient beds. • Heart failure accounts for 5% of all emergency medical admissions to hospital.
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Assessment of patients with chronic heart failure Structure and function of the heart The heart is a muscular pump that propels oxygenated blood around the body. It is situated in the chest cavity and surrounded by the pericardium. It is divided into two halves which in turn are divided into two chambers, with the upper two chambers being the atria and lower two being the ventricles.
Exercise 6.1 Identify the structures on this diagram of the heart, and check your answers in an anatomy and physiology book. Visit the following website to see the heart and how it functions: www.hhmi.org/biointeractive/vlabs/cardiology/content/cg/basic.htm or to hear different heart sounds go to: http://depts.washington.edu/physdx/heart/demo.html.
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Ann Saxon and Sue Lillyman Definition of heart failure According to the British Heart Foundation (2009), heart failure is a term used to describe the symptoms and signs that occur if the heart is not pumping blood around the body efficiently. It is an abnormality of cardiac function whereby the heart becomes less efficient at pumping blood around the body, either at rest or when exercising. This results in congestion, or ‘back-log’ within the circulation.
Scope of assessment Symptoms Heart failure has a complex disease process, in which some of the following signs and symptoms are seen: • Dyspnoea. • Palpitations. • Peripheral oedema. • Fatigue. • Lethargy. • Exercise intolerance. • Chest pain. • Anxiety and depression. • Confusion.
Models of consultation Models of consultation have been previously covered in this book (see Chapters 2 and 3), however the best model to use will depend on the nature of the individual patient’s condition. Most primary care trusts and acute hospitals have developed specific pathways for caring for patients with CHD, in particular for those with heart failure. Two examples are: • The Darlington Model (Wilkinson, 2000). • The Wallasey Heart Centre Heart Failure Programme (Cummins et al., 2003) It is frequently found that patients who present with heart failure already have had a diagnosis of the condition. However it may be necessary to utilise your clinical decision-making skills to rule out complications or other chronic diseases.
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Assessment of patients with chronic heart failure History-taking and investigations The NICE Guidance for Heart Failure (National Institute for Health and Clinical Excellence, 2010) recommends taking a careful and detailed history. The following clinical examinations would be required: • 12-lead electrocardiogram (ECG). • Chest X-ray. • Blood tests and full blood count. • Urea and electrolytes (U&Es). • Creatinine levels. • Thyroid function tests. • Liver function tests. • Glucose levels. • Lipid analysis. • Urinalysis. • Peak flow. • Spirometry.
Functional capacity and quality of life Quality of life issues for patients with heart failure are an important aspect of every assessment. Depending on the model of assessment used, all of the patient’s normal daily activities should be assessed. Their functional capacity should also be assessed to establish the impact the disease has on their daily life, particularly with respect to activities that are mostly taken for granted. Several tools have been developed to assist practitioners in their assessment of functional capacity: • The New York Heart Association Classification (Heart Failure Society of America, 2009). • The Six-Minute Walk Test (American Thoracic Society, 2002). • The Short-Form SF-36 (Quality Metric, 2007). The New York Heart Association (NYHA) system provides a simple way of classifying the extent of heart failure. It places patients in one of four categories based on the degree to which they are limited during physical activity, with respect to normal breathing and varying degrees of shortness of breath or pain from angina (see Table 6.1). This is used to ascertain the patient’s progress and ability to cope with the disease and the increasing limitations on their lives.
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Ann Saxon and Sue Lillyman Table 6.1 New York Heart Association (NYHA) system of classification (National Institute for Health and Clinical Excellence, 2003)
Grade
Symptoms
I
No symptoms and no limitation in ordinary physical activity (e.g. shortness of breath when walking, climbing stairs, etc.)
II
Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
III
Marked limitation in activity due to symptoms, even during lessthan-ordinary activity (e.g. walking short distances of 20–100 metres). Comfortable only at rest.
!V
Severe limitations. Experiences symptoms even while at rest. Mostly bed-bound patients.
The six-minute walking test (American Thoracic Society, 2002) is carried out in the following way: • The patient walks as far as possible, indoors, on the flat, for six minutes (the patient can stop walking if required, but is asked to put in their best effort). • The distance the patient walks on a second attempt (after a practice run) is recorded. • The patient is asked to assess the degree of breathlessness they experience before and after the walk using a visual analogue scale (Fig. 6.1). You should also evaluate what limits the patient’s exercise capacity, whether it is fatigue or dizziness for example.
Figure 6.1 Visual analogue scale (VAS) for degree of breathlessness (Education for Health, 2008).
Fluid status Signs and symptoms of heart failure include tachycardia and venous congestion, otherwise known as oedema. It is therefore important through
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Assessment of patients with chronic heart failure your examination to note any signs of oedema and tachycardia, by carrying out a physical assessment with the following baseline observations: • Pulse. • Blood pressure (both lying and standing measurements). The cardiac rhythm is also noted, and the minimum assessment for tachycardia would be recording the patient’s pulse.
Cognitive state As with several other long-term conditions, the patient may experience some changes in cognitive ability. Where this is affecting the patient to a significant extent, information should be gathered from the patient’s relatives and carers. Suitable assessment tools include those that have been developed to assess aspects of anxiety and depression, for example: • Hospital Anxiety Depression Tool (Snaith, 2003): This inventory has been widely adopted for use in primary care settings. It has fourteen questions that ask patients to rate their mood and anxiety levels. • GAD-7 Anxiety Screening Tool (Spitzer et al., 2006): This is a useful self-administered patient questionnaire that can be used for a screening and for measuring the severity of generalised anxiety disorders. • Beck Depression Inventory (Beck et al., 1961): This was first published in 1961 and comprises twenty-one multiple choice question in a self- reporting inventory. It has been adopted widely by health professionals to measure the severity of depression. There are currently three versions and they can be used with anyone above the age of thirteen.
Information about programmes for improving access to psychological therapies A national programme has been set up to support frontline staff in implementing the NICE guidelines for people suffering from depression and anxiety disorders (IAPT) (Department of Health, 2008).
This can be found at www.iapt.nhs.uk.
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Ann Saxon and Sue Lillyman Nutritional status Due to the nature of the symptoms of heart failure, patients may experience loss of appetite and weight fluctuations. Nutritional assessment is important and can be assessed using a tool such as the MUST (or the Malnutrition Universal Screening Tool).
This is available at www.bapen.org.uk.
Patient management Aims of good management The aims of good management of patients with chronic heart failure are to: • Relieve anxiety and pain. • Ensure adequate oxygenation. • Maintain adequate tissue perfusion. • Clear any pulmonary and peripheral oedema. • Re-establish stable cardiac status. • Prevent recurrence.
Pharmacological intervention The range of prescribed medications for people with chronic heart failure may include: • Diuretics. • ACE inhibitors. • Beta-blockers. • Digoxin.
Patient review and medication review As part of the review process for patients with heart failure, a careful evaluation should take place as suggested by the NICE guidance (National Institute for Health and Clinical Excellence, 2010). Depending on the severity of the patient’s condition, a clinical review should be carried out between two weeks and six months after initial presentation. The NICE guidelines suggest that practitioners should develop a communication strategy that covers the following aspects:
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Assessment of patients with chronic heart failure • Listen to the patient. • Use words that are easily understood. • Explain any side effects of the medication. • Give important information first. • Summarise in the patient’s own words. • Choose words carefully and avoid medical jargon. • Make use of patient leaflets to explain important areas of care. • Involve other members of the family, as required, and after gaining the patients’ consent. For many patients with heart failure, it is essential to consider many factors that may influence a patient’s recovery or progression of the disease. The following areas should be considered: • Pharmacological interventions. • Exercise training and rehabilitation. • Smoking. • Alcohol. • Sexual activity. The review and assessment of a patient with heart failure should be carried out as part of a pathway of care and it is important that the approach takes into account the multiprofessional team.
Exercise 6.2 Review the plan of care that you use for the care of heart failure patients. What evidence is available to support the development of care pathways?
Medication review It is important to monitor the patient’s progress when medication has been prescribed, and to carry out a full medication review on each occasion in order to establish whether the patient is coping with the treatment regimen, as well as to monitor any untoward side effects. The medication review includes
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Ann Saxon and Sue Lillyman the dose of the medication, the type of medication and the side effects of the medication. This review is crucial because it: • Optimises therapy. • Improves health outcomes. • Reduces the likelihood of medicine-related problems. • Reduces waste of drugs. • Enables patients to maintain their independence and avoid care at home or hospital admission. • Improves patient understanding. • Increases patient satisfaction. The key elements of the review are: • To obtain a list of all the medications being taken. • To check the appropriateness of the medications. • To check the patient’s understanding of the medication. • To identify any side-effects. • To identify any drug interactions. • To identify any monitoring and tests that need to be carried out. • To address practicalities of the patient’s ability to take medications safely. • To check patient concordance and compliance with their regimen.
Case Study 6.1 Mr P is a 52-year-old Caucasian man who has a history of angina. He presents with swelling of his ankles and legs and is short of breath on exertion. He complains that he has lost his strength. He finds it hard to lie down to sleep as he feels he cannot breathe properly and sometimes wakes up gasping for breath. He complains that he has a constant cough, cannot eat properly, and has recently lost weight. He is concerned that he cannot concentrate on his work any more due to being so tired. He has not smoked for 10 years although he always has a gin and tonic when he gets home from work and drinks socially at the weekend when he feels up
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Assessment of patients with chronic heart failure to going out. He is a little overweight, but not obese. He has not done any exercise for the last few years due to the pressure of work and now because he is feeling very tired. Lifestyle factors For many patients with heart failure, it is essential to consider lifestyle factors when carrying out a review as they may be influential in a patient’s recovery or progression of the disease. These include cigarette smoking, alcohol use, cultural factors and sexual activity.
Exercise 6.3 What investigations would you need to carry out to help diagnose the condition of Mr P in Case Study 6.1? List the factors that would influence Mr P’s compliance with his medication regimen. What could a health professional do to involve Mr P in the decision-making process?
Patients should be strongly advised to quit smoking. However, this is not always easy for people faced with a chronic health condition. Health professionals need to have professionals and support staff who are trained in smoking cessation and are able to provide supported classes for patients. The National Health Service has a quit-smoking helpline and can also offer supported training.
A useful resource can be found at www.smokefree.nhs. It is also important for all services to be sensitive to the cultural needs of the patient. Some areas demonstrating good practice (Department of Health, 2004) are: • Manchester NHS Trust, working with the Muslim Council of Britain and the Islamic Council of Britain.
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Ann Saxon and Sue Lillyman • British Heart Foundation’s Quit Ramadan campaign. • The New Leaf Project in Nottingham. Assessment should also include the amount of alcohol a patient consumes in a week. Every effort should be made to encourage the patient to reduce the amount of alcohol they drink and to tailor advice according to the clinical condition of the patient.
The WHO Audit questionnaire is recommended for screening for alcohol misuse, and this can be found at www.actiononaddiction.org.uk/addiction/alcohol/alcohol_questionniare. Healthcare professionals should be prepared to discuss sexual activity with heart failure patients because embarrassment often prevents patients from broaching the subject themselves. Referral to other agencies may help where required.
Exercise 6.4 Review the information you have available for patients related to smoking cessation and alcohol use. Reflect on the assessment skills you have learnt related to heart failure and add some action points linked to your new learning. Exercise training and rehabilitation Patients with heart failure should be encouraged to take part in some form of exercise or rehabilitation programme. The type of activity will depend on the severity of the condition and each patient’s mobility. GPs may recommend a supervised cardiac programme at the local hospital or primary care centre, and some healthcare trusts have specific programmes designed for the needs of their local populations. Exercise programmes come in various forms, such as: • Walking. • Cycling on a stationary bike. • Using a treadmill.
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Assessment of patients with chronic heart failure • Low-impact aerobics. • Tai chi. • Use of light weights.
One useful website, where information is also available in many different languages such as Urdu, Hindi, Punjabi and Bengali, can be found at: www.bhf.org.
Exercise 6.5 List the benefits of regular exercise to patients with heart failure. What strategies would you use to promote this activity (you may include use of leaflets)?
Conclusion Heart failure is not an exact diagnosis but the condition develops as a complication of various conditions associated with the heart. For this reason it is difficult to give patients a prognosis, although in situations where the condition is severe the symptoms will become gradually worse over time. New treatments are constantly being developed which means that the outlook for these patients is always improving.
References and further reading American Thoracic Society (2002). Statement Guidelines for the Six-Minute Walk Test. American Journal of Critical Care Medicine 166, 111–117. Beck, A.T., Ward, C.H., Mendelson, M. et al. (1961). An inventory for measuring depression. Archives of General Psychiatry 4, 561–571. British Heart Foundation (2009). Health professionals successes. Available at: http://www.bhf. org/research_health_professionals_successes/heart_failure.aspx (accessed April 2011).
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Ann Saxon and Sue Lillyman Cowie, M.R., Wood, D.A., Coats, A.J.S. et al. (1999). Incidence and aetiology of heart failure: a population-based study. European Heart Journal. 20; 421–428. Cummins, A., Rimmer, F., Farrar, A., et al. (2003). Cardiovascular partnerships: Wallasey Heart Centre. A working model. Cardiology News 6(2), 2–3. Department of Health (2000). National Service Framework for Coronary Heart Disease. London: Department of Health. Department of Health (2004). Heart Disease and South Asians. Delivering the National Service Framework for Coronary Heart Disease. London: Department of Health. Department of Health (2007). Raising the Profile of Long-term Conditions Care: A Compendium of Information. London: Department of Health. Department of Health (2008). Improving Access to Psychological Therapies (IAPT). Outcomes Toolkit. London: Department of Health. Education for Health (2008). Simply COPD. A Practical Guide, 5th edn. Warwick: Education for Health. Heart Failure Society of America (2009). Heart Failure Practice Guidelines. Available at: http://www.onlinejcf.com/article/S1071-9164(10)00174-0/fulltext (accessed April 2010). National Institute for Health and Clinical Excellence (2003). Chronic Heart Failure. Management of Chronic Heart Failure in Adults in Primary and Secondary Care. London: NICE. National Institute for Health and Clinical Excellence (2010). CG108 Chronic Heart Failure: Full Guidelines. London: NICE. Pearson, M. and Cowie, M. (eds) (2005). Managing Chronic Heart Failure: Learning from Best Practice. London: Royal College of Physicians. Petersen, S., Rogers, M, and Wolstenhome, J. (2002). Coronary Heart Disease Statistics: Heart Failure Supplement. London: British Heart Foundation. Quality Metric (2007). A new chapter for the SF-36 (v2) Health Survey. Available at: http:// www.qualitymetric.com/WhatWeDo/SFHealthSurveys/SF36v2HealthSurvey/tabid/185/ Default.aspx (accessed April 2011). Snaith, R, (2003). The Hospital Anxiety Depression Scale. Health and Quality of Life Outcomes 1, 29. Spitzer, R.L., Kroenke, K., Williams, J.B. et al. (2006). A brief measure for assessing generalized anxiety disorders: the GDD-7. Archives of Internal Medicine 166(10), 1092–1097. Wilkinson, I. (2000). The Darlington assessment systems clinical guidelines for practitioners. Journal of Family Therapy 22(2), 211–224. World Health Organization (2008). The Top Ten Causes of Death. Factsheet No. 310. Geneva: WHO.
Useful web resources British Cardiac Patients Association www.bcpa.co.uk
British Heart Foundation www.bhf.org.uk
Heart failure matters
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Assessment of patients with chronic heart failure www.heartmatters.org
Heart UK www.heartuk.org.uk
National Institute of Clinical Excellence www.nice.org.uk
National Prescribing Centre for case studies (with teaching packages and up-to-date information in relation to treatment) www.npci.org.uk
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Chapter 7
Assessment of patients with diabetes mellitus Ann Philp and Ann Saxon
Key areas Aims of diabetes care Statistics and NICE guidance Scope of assessment Neurological, vascular and abdominal examination Psychological and behavioural assessment
Introduction Diabetes is a long-term condition with life-long implications for the patient. The over-riding aim is to minimise complications of the condition and improve the patient’s quality of life, so they can control their condition and live a fulfilled life. Diabetes mellitus is a chronic and progressive illness that affects people of all ages. It can affect children, young people and adults, and is becoming more common on a worldwide scale. Indeed, incidence is increasing in all age groups. Currently there are 1,800,000 people diagnosed in the UK with diabetes, and hundreds more people may have type 2 diabetes without yet knowing (Department of Health, 2008). Nearly 3 million people are currently diagnosed with diabetes in the UK and this figure is increasing every year (Department of Health, 2008), with predictions that it will reach the three million mark by 2020. Currently the NHS spends close to 10 million pounds per day treating diabetes and its effects (Diabetes UK, 2004). It is important to note that the prevalence of type 2 diabetes is closely linked to being overweight (Williams
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Ann Philp and Ann Saxon and Pickup, 2004) and that prevalence is around five times higher in people from African–Caribbean or Asian backgrounds in the UK (Diabetes UK, 2004).
Types of diabetes There are two main types of diabetes mellitus, type 1 and type 2. Type 1 accounts for 5–10% of all diagnosed cases, while type 2 accounts for 85– 90% of patients (Kumar and Clark, 2005). Type 1 diabetes is an autoimmune disease in which the body’s immune system attacks and kills off its own insulin-producing cells. In type 2 diabetes, the insulin that the body produces is less efficient at removing sugar from the bloodstream. Type 2 diabetes is said to be an adult-onset disease, however more children are presenting with the condition (Rubin, 2008). Other, less common types of diabetes include gestational diabetes, diabetes due to the side-effects of steroid therapy, and diabetes associated with hormonal disorders, such as maturity-onset diabetes of the young, cystic fibrosis-related diabetes, and Cushing’s syndrome. Cushing’s syndrome is caused by prolonged exposure of the body tissues to high levels of the hormone cortisol (Porth and Bruyere, 2009). In high-risk groups, diabetes can lead to potential complications if not managed and treated correctly. These include macrovascular and microvascular complications that can sometimes be influenced by cultural factors.
Exercise 7.1 Identify the structures on this diagram of the liver and pancreas.
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Assessment of patients with diabetes mellitus
Significant clinical studies and guidance There has been a growing evidence base to support the care and treatment for patients with diabetes and the underpinning research has enabled patients to live a fuller life with the condition. As a health professional it is important to understand some of this evidence base and research. It would be useful for you to engage in further reading and look at some of the important statistics related to diabetes. These can be found in the National Service Framework (Department of Health, 2003), the NICE guidelines (National Institute for Health and Clinical Excellence, 2004, 2008, 2009), the Diabetes Control and Complications Trial, the UK Prospective Diabetes Study, the Action in Diabetes and Vascular Disease (ADVANCE) study, the Action to Control Cardiovascular Risk in Diabetes study and Diabetes UK (for more information, see Useful web resources at the end of the chapter). These studies have had a major impact on the care and treatment of patients with diabetes. They show that keeping the blood glucose as close to normal as possible slows down the development of complications, in particular renal disease and eye disease.
For more information see: http://diabetes.niddk.nih.gov/dm/pubs/control/#DCCTxt.
National Service Framework (NSF) The National Service Framework (Department of Health, 2003) or NSF for diabetes was set up to improve services by setting national standards for diabetes care. This is valuable because of the variations found in caring for patients across the UK, and the quality standards it defines will help improve the quality of life of patients with diabetes.
NICE guidelines The National Institute for Health and Clinical Excellence (NICE) produced guidance for both type 1 and type 2 diabetes in 2004 and 2008, which were developed to make recommendations on the most appropriate type of treatment and care for people suffering with the disease. They are based on the best available evidence and will help you further develop your assessment skills of the patient who has diabetes. The aims of the more recent (2009) guidelines are to: • Provide recommendations for the treatment and care of people with diabetes by health professionals.
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Ann Philp and Ann Saxon • Develop standards for assessing the clinical practice of individual health professionals. • Improve the education and training of health professionals. • Help patients to make informed decisions. • Improve communication between patients and health professionals.
Guidelines for type 1 diabetes can be found at www.nice.org.uk/CG1.
Guidelines for type 2 diabetes can be found at www.nice.org.uk/CG66.
Action to Control Cardiovascular Risk in Diabetes (ACCORD) study In an effort to evaluate the heart disease imposed by diabetes, the National Institute of Health sponsored a trial on cardiovascular risk in diabetes. The ACCORD study commenced in the early 1990s, enrolling approximately 10,000 patients with type 2 diabetes. The study found that a therapeutic strategy for maintaining blood sugar at near-normal levels reduced cardiovascular events, however these results were inconclusive because they related to lowering blood sugar only, and heart disease has many other contributing factors and these were all high-risk patients (according to the National Heart and Lung Institute), that is those who had had a heart attack, or high cholesterol or high blood pressure.
For a summary see Nilsson (2005) or for further information see: www.nhlbi.nih.gov/health/prof/heart/other/accord/.
Action in Diabetes and Vascular Disease (ADVANCE) study ADVANCE is the largest clinical trial on diabetes that has ever been conducted. It commenced in 2001 and the recruitment stage ended in March 2003, with over 11,000 patients from more than 20 different countries. The main areas of the study were completed in 2008, and were focused on four major areas including the blood glucose-lowering and blood pressure-reducing effects of treatments. Observations also included eye health and heart function, as well as cost-effectiveness and quality of life.
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Assessment of patients with diabetes mellitus More information about this trial can be found at www.medicalnewstoday.com/articles/99074.php.
Scope of assessment When assessing the patient with diabetes it is important that you choose an appropriate model to cover all aspects of care (see Chapters 2 and 3 for models of assessment). Reliable and regularly updated information is very important for ensuring appropriate management and treatment of these patients. You should obtain a full and detailed history at the first visit, because the majority of patients with newly diagnosed type 2 diabetes have had diabetes for over 10 years and they will have complications by the time that diagnosis is made. Therefore a comprehensive assessment is required. The goal is to know your patient.
Personal details and history-taking It is always important to record basic information such as the patient’s name, date of birth, address and contact details, as well as those of carers and neighbours. The patient’s history should cover: Present history: what happened in the lead up to the current symptoms and the reason they made this hospital or GP appointment. Previous medical history: including co-morbidities and allergies. Family history: check for any familial diabetes, cardiovascular disease, renal disease, autoimmune disease or neuropathic disease. As with other chronic conditions it is appropriate in assessing the patient with diabetes to assess some of the lifestyle factors that may influence their control of the condition. The following areas should be covered: • Healthy eating. • Smoking (number of years as a smoker and packs per day). • Alcohol intake (number of units consumed weekly). • Physical activity. • Driving. • Occupation and employment (active or sedentary, shift-work, driving) or retired status. • Use of prescribed drugs (e.g. statins, steroids, oral contraceptives, thiazides, beta-blockers). You may need to warn the patient about the possible hypoglycaemic side effects of some medications.
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Ann Philp and Ann Saxon Information on social history, leisure activities and exercise habits is very valuable, as is any information about the patient’s mobility, religious and cultural beliefs, any special dietary information, and whether they receive support from a social worker. From your assessment it may be then necessary to refer the patient on to specialist services such as a dietician, a smoking cessation clinic or an exercise programme. You should find out also what language or languages they speak and whether they can communicate effectively. They may need an interpreter or have some hearing or visual impairment, or a speech defect.
General observations and laboratory tests Clinical examination should include a range of observations and laboratory tests, such as: • Height, weight and body mass index. • General fitness level (through interviewing). • Baseline cardiovascular observations including blood pressure, pulse and electrocardiogram (ECG). • Respiratory system observations such as respiration rate and depth of breathing. • Blood glucose (e.g. finger prick test). • Urinalysis. • X-rays of the chest and foot.
Abdominal examination Check the patient’s body shape. Is it pear-shaped or apple-shaped? Is the patient obese? Palpate for renal tenderness and check for hepatomegaly. Check genitalia for any swelling or abnormalities.
Vascular examination Check the skin and blood vessels primarily for tissue viability and any signs of circulatory problems, such as dilated veins, wounds, redness, hotness or oedema, particularly Charcot’s foot (see below). Also check the pulse rate and the condition of the patient’s nails. Peripheral vascular disease is a complication of diabetes that can lead to amputation of a limb or extremity and even death. It can occur in any age group and can rapidly deteriorate. It can be detected by recording foot pulses, and assessed by Doppler echocardiography. As with any skill, it is important that the practitioner is correctly trained in the use of any equipment and
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Assessment of patients with diabetes mellitus technique, such as Doppler assessment. Frequent use of the equipment under supervision will ensure a good level of competence is achieved.
Foot examination This is an essential aspect of care for the patient with diabetes. Assessment of the foot is important for prevention and detection of a worsening condition. As well as revealing peripheral vascular disease, examination can reveal Charcot’s foot. This relatively rare condition can be very serious. The patient usually presents with a hot swollen, red foot, with recent collapse of the medial arch (Karet, 2009). There is rapid degenerative arthritis of the foot, which can lead to gross deformity, so patients who present with this condition should be advised not to put any weight on the foot until they have been fully assessed. Simple but effective assessment of the foot can facilitate early diagnosis and treatment (Fig. 7.1). It involves. • Inspection. • Monofilament sensation tests. • Palpation of pulses.
Fig. 7.1. Foot pulse examination.
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Ann Philp and Ann Saxon Referral to specialist services is usually advisable for patients with hard calluses that require treatment.
Neurological examination This should include the eyes and hearing, as well as looking for signs of neuropathy and postural hypotension. Peripheral neuropathy is a common complication of diabetes. Changes in the circulation can be easily detected with some simple tests carried out in the routine visit to the GP or other health professional. These are: • Sensitivity to light touch (monofilament). • Sensitivity to vibration (using a tuning fork). • Skin temperature. • Pain perception. Patients may also need to be referred to the retinal screening programme to establish whether they are at risk of developing retinopathy.
Psychological and behavioural assessment Patients who are diagnosed with diabetes have different reactions to the diagnosis, and for some it may lead to depression and behavioural difficulties. It may be helpful in the assessment process, therefore, to make use of a specific assessment tool (see Chapter 6) to ascertain the patient’s mood and behaviour, and establish a suitable plan of care.
Management of the patient Aims of care The aim of diabetes care is to return the patient to as close a non-diabetic state as is safe and practical for that particular person. The following targets should be aimed for (these are for adults). They are derived from the Joint British Societies’ Guidelines on the Prevention of Cardiovascular Disease in Clinical Practice (British Heart Foundation, 2006). • Non-smoking status. • Waist circumference of less than 102cm for men (92 cm in Asian men) and less than 88cm in women (78 cm in Asian women). • Body mass index of 18.5–25.0kg/m2 • Blood pressure (without postural hypotension) of below 130/80mmHg (or 125/75mmHg in patients with renal disease).
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Assessment of patients with diabetes mellitus • Fasting lipid levels: total cholesterol of less than 4mmol/L or a 25% reduction (whichever is lower) or LDL (low-density lipoprotein) cholesterol of less than 2mmol/L or a 25% reduction (whichever is lower). • Fasting triglyceride of less than 1.7mmol/L. • Fasting plasma glucose of 4–6mmol/L (without hypoglycaemia). • Glycosylated haemoglobin (HbA1c) of 6.0–6.5% (without hypoglycaemia). • No high-glucose emergencies. • Normal urinary albumin to creatinine ratio of > 2.5mg/mmol (men) or > 3.5mg/mmol (women) or albumin concentration > 20mg/L.
Treatment options Treatments for diabetes include dietary modification, oral hypoglycaemic agents, insulin therapy and incretin mimetics. Many patients who present with diabetes may also have another chronic long-term condition and may be on multiple drug treatments. It is important during medication reviews, therefore, to check that the patient is complying with their medication regimen. If they are not, then you will need to establish what measures would help them comply with the regimen.
Care planning and review A plan of care might include: • Patient-centred initial targets. • Establishing what support is required. • Exchanging information. • Ensuring the patient has a record of their care plan. Handheld records are comprehensive accounts of the patient’s diagnosis, plan of care and treatment regimen, and can be accessed by the multiprofessional team and are used to improve communication across primary and secondary care settings. Reliable and regularly updated information is essential for ensuring appropriate management and treatment of these patients, and the patient’s care plan may need to be renegotiated at different stages. Changing lifestyle factors may influence their control of the condition, and the patient may be attending specialist services such as a diet clinic or smoking cessation clinic or undertaking an exercise programme.
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Ann Philp and Ann Saxon All of the above aspects should be reviewed on a regular basis and at the annual review. This must include: • Blood tests. • Clinical assessment. • Success of self-management. • Success of lifestyle and behaviour modification.
Patient education There is a plethora of information available about the care and treatment of diabetes, so it is important to explore the following during the assessment process: • The patient’s existing knowledge. • The presence of any barriers to learning. • The needs of the patient’s family. • The degree of carer involvement.
Case Study 7.1 Mr K is a 67-year-old Asian man who was discharged from hospital following stabilisation of his blood sugar after his recent diagnosis of type 2 diabetes. He was around 20 kilograms overweight and has trouble with his mobility because of his weight and arthritis. He has been put on a diet and told to lose more weight. He has been prescribed metformin but says it makes him feel a little sick. He has come to the health centre to be assessed and for information on how to cope with his condition. He is concerned about his future and how he will cope with running his shop and caring for his family. Previously he has had high blood pressure and informs you that he had chest pain about a year ago, but he did not visit his GP at the time. Until his diagnosis, he had only taken pain-killers for this chest pain and for pain in his ankles and knees, and he noticed that he had been drinking a lot. He had lost around 13 kilograms in weight before diagnosis, without trying. He eats an Asian diet prepared by his wife, and lives in a detached house with his wife and one of his daughters. He tells you that he feels very tired and points out a sore on his foot that is taking a long time to heal.
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Assessment of patients with diabetes mellitus His parents are both deceased. His mother died of a stroke and he thinks his father had diabetes. All his siblings are alive and well. He wears glasses for reading, but has no problems with his hearing, and can communicate well in English. He was a smoker when he was younger and he does not drink alcohol.
Exercise 7.2 Use the Case Study 7.1 as you consider the aspects of care listed below, from Pendleton’s consultation model (1984). Include information on Mr K’s personal details, his clinical history, physical examination, observations and investigations, treatment options, lifestyle issues, education requirements and psychological well-being. Information required from patient Reason for attendance at the clinic Presence of related problems Investigations to be carried out Development of shared understanding Patient involvement in management of condition Appropriate use of time and resources Establishing and maintaining relationships
In their guidance on the use of patient education models for diabetes, NICE state: ‘It is recommended that structured patient education is made available to all people with diabetes at the time of initial diagnosis and then as required on an ongoing basis, based on a formal, regular assessment of need’ (National Institute for Health and Clinical Excellence, 2003). Insufficient evidence is currently available to recommend a specific type of education or provide guidance on the setting for (or frequency of) sessions. However, to achieve maximum effectiveness, some principles of good practice are clear with respect to educational interventions: • They should reflect established principles of adult learning. • They should be provided by appropriately trained multidisciplinary
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Ann Philp and Ann Saxon teams to groups of people with diabetes, unless group work is considered unsuitable for a particular individual. • They should be accessible to the broadest range of people, taking into account their culture, ethnicity, disability and geographical issues, and could be held in the community or at a local diabetes centre. • They should use a variety of techniques to promote active learning and to engage patients in the process of learning. • The content should be related to personal experience, adapted wherever possible to meet the different needs, personal choices and learning styles of people with diabetes, and should be integrated into routine diabetes care over the longer term.
Here are some educational programmes and education providers: Dose Adjustment for Normal Eating (DAFNE) www.dafne.uk.com/index.html Expert Patient Programme www.expertpatients.co.uk X-pert Diabetes Education Programme www.xperthealth.org.uk Diabetes UK (for local programmes) www.diabetes.org.uk Management of Diabetes for Excellence (MODEL) are a group of healthcare professionals who published a report in 2007 calling for a higher level of diabetes care in England and Wales (Management of Diabetes for Excellence, 2007). Other structured education programmes, such as DAFNE, Diabetes INSIGHT, Developing Quality Structured Education in Diabetes (DESMOND) (2011) and X-Pert, give support to diabetes patients on how to live with diabetes through lifestyle management (for more information, see Useful web resources at the end of the chapter). However, many people are unable to benefit from them because of financial or geographical constraints. It is vital that access to specialist skills is available for people presenting with difficult diagnoses, or those with complex management regimens (including those with erratic glucose control) or those needing care for diabetic complications. The patient should be able to draw on the different skills of healthcare team members, moving between them according to their need.
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Exercise 7.3 Find out in your local area what education programmes are available to patients with diabetes. How easily are they accessed? Are they run by professionals or patient groups?
Conclusion Diabetes is a long-term condition that the individual will have to learn to live with from the point of diagnosis. Working with the patient can help reduce the complications of the condition and improve their quality of life, and the resources described here can help empower people living with diabetes to control the condition and live a fulfilled life.
References and further reading British Heart Foundation (2006). Joint British Societies’ Guidelines on the Prevention of Cardiovascular Disease in Clinical Practice: Risk Assessment (JB52). London: British Heart Foundation. Department of Health (2003). National Framework for Diabetes. London: Department of Health. Department of Health (2008). Five years on. Delivering the diabetes National Service Framework. London: Department of Health. Diabetes UK (2004). Diabetes in the UK 2004. A report from Diabetes UK. Available at http://www.diabetes.org.uk/Documents/reports/in_the_uk_2004.doc (accessed April 2011). Karet, B. (2009). Hypo affects more diabetics than previously thought. Available at: http://www.diabetes.co.uk/news/2009/Oct/hypo-affects-more-diabetics-than-previouslythought.html (accessed April 2011). Kumar, P. and Clark, M.L. (2005). Algorithmic evaluation of metabolic control and risk of severe hypoglycaemia in type 1 and type 2 diabetes using self-monitoring blood glucose measures. Diabetes Technology and Therapeutics 5(5), 817–828. Management of Diabetes for Excellence (MODEL) (2007). Diabetes: finding excellence? Facing the multi-faceted challenge of diabetes. Available at: http://www.novonordisk.co.uk/ Images/2007/.pdfs/MODEL_final_LR.pdf (accessed April 2011). National Diabetes Information Clearinghouse (1993). Diabetes Control and Complications Trial (DCCT) and Follow-up Study. Available at: www.diabetes.niddk.nih.gov/dm/pubs/control/ (accessed April 2011).
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Ann Philp and Ann Saxon National Institute for Health and Clinical Excellence (2003). Guidance on the Use of PatientEducation Models for Diabetes. London: NICE. National Institute for Health and Clinical Excellence (2004). Diagnosis and Management of Type 1 Diabetes in Children, Young People and Adults. London: NICE. National Institute for Health and Clinical Excellence (2008). Type 2 Diabetes (partially updated by CG87). London: NICE. National Institute for Health and Clinical Excellence (2009). NICE and Diabetes. A Summary of Relevant Guidelines. London: NICE. Nilsson, P. (2010). ACCORD and risk factors control in type 2 diabetes. New England Journal of Medicine, 362, 1628–1630. Pendleton, D., Schofield, T. and Tare, P. (1984). The Consultation: An Approach to Teaching and Learning. Oxford: Oxford University Press Porth, C.M. and Bruyere, H.J. (2009). Pathophysiology Concepts of Altered Health States, 8th edn. London: Lippincott, Williams and Wilkins. Rubin, A. (2008) Diabetes for Dummies, 3rd edn. Wiley: Indiana. Williams, G. and Pickup, J. (2004). The Handbook of Diabetes. Oxford: Blackwell.
Useful web resources Action in Diabetes and Vascular Disease (ADVANCE) www.advance-trial.com/static/html/prehome/prehome.asp
Action to Control Cardiovascular Risk in Diabetes (ACCORD) www.nhlbi.nih.gov/health/prof/heart/other/accord/
Developing Quality Structured Education in Diabetes (DESMOND) www.desmond-project.org.uk
Diabetes-Insight (INSIGHT) www.diabetes-insight.info
Diabetes UK www.diabetes.co.uk
Dose Adjustment for Normal Eating (DAFNE) www.dafne.uk.com
National Diabetes Information Clearinghouse (NDIC) for the Diabetes Control and Complications Trial (DCCT) and follow up study www.diabetes.niddk.nih.gov
National Prescribing Centre Information www.npci.uk
UK Prospective Diabetes Study (UKPDS) www.dtu.ox.ac.uk
X-Pert www.xperthealth.org.uk
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Chapter 8
Assessment of patients with musculoskeletal pain Mary Drozd and Gail Parsons
Key areas Anatomical positions Review of other body systems Physical examination of the joints Pain assessment Range of movements Patient management
Introduction The musculoskeletal system includes bones, joints, muscles, ligaments, cartilage, tendons and nerves (Bulstrode and Swales, 2007). Musculoskeletal disorders are the commonest cause of disability in the UK and patients with such conditions form 20–25% of a GP’s workload (Arthritis Research Campaign (ARC), 2005). Alongside this, a large proportion of attendances in the emergency department are associated with injuries of the musculoskeletal system (Dolan and Holt, 2000). Correct diagnosis depends on knowledge of functional anatomy, together with an accurate patient history, diligent observation and a thorough examination (Magee, 2006). An initial history must also be completed (see Chapter 4).
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Exercise 8.1 Identify the structures on these diagrams of the knee joint and the hip joint. You can check your answers in an anatomy and physiology book or at www.patient.co.uk.
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Anatomical (neutral) position In the anatomical position, the patient stands erect with feet slightly separated, arms hanging relaxed by the side with palms facing forward and thumbs pointing away from the body. Understanding the neutral or anatomical position of the human body, as well as the various movements associated with each joint, is important when describing the location of the patient’s symptoms or the movements the patient is able to perform. The anatomical position is the reference position for defining body movements. It relates to the position of the limbs in relation to the body, thus: Superior: location towards the head or upper part of the body. Inferior: location towards the lower part of the body. Anterior: location towards the front of the body. Posterior: location towards the back of the body. Medial: location towards or at the midline of the body. Lateral: location away from the midline of the body. Proximal: location closer to the point of attachment of a limb. Distal: location further away from the point of attachment of a limb (e.g. the knee is distal to the thigh).
Scope of assessment History-taking History-taking is vital prior to the physical examination (Bickley, 2007; Epstein et al., 2003; Magee, 2006). Initially the patient’s chief complaint is established, and this should be in the patient’s own words. The onset of the complaint needs to be ascertained, as well as any history of injury. Various systems are used for history taking, but it is of utmost importance to use a sequential method so that nothing is overlooked (Magee, 2006), The schedule might cover the following points. • The chief complaint (in the patient’s own words). • The onset of the chief complaint. • The history of any injury. • Previous surgical operations or medical procedures like lumbar puncture. • Previous medicine and alternative treatment for the chief complaint.
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Mary Drodz and Gail Parsons • Allergies (medical and environmental). • Family history. • Occupation and social history.
Exercise 8.2 What may be a suggested schedule for assessment?
Review of other body systems • Has the patient experienced any weight loss or gain? • Has the patient experienced any problems with the activities of daily living? • Has the patient experienced any disruption of sleep? Review of systems will follow on from this initial stage. You should establish whether the patient is under the care of any other healthcare specialists so that the presenting condition is seen in the context of the whole patient. You need to understand the other systems of the body because, for example, cardiac pain can be mistaken for musculoskeletal pain, and renal problems can manifest as back pain. You will also need to ‘red flag’ any findings in the patient history that indicate a need for referral to a physician. Red flags may include the following (Magee, 2006): • Persistent pain at night. • Constant pain. • Unexplained weight loss. • Loss of appetite. • Unusual lumps or growths. • Unwarranted fatigue. • Constant and severe pain in lower leg (calf) or arm. • Swelling or redness of a joint with no history of injury. • Discoloured feet. • Fever or night sweats. • Problems with balance, coordination or falling.
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Exercise 8.3 List the common symptoms affecting the musculoskeletal system in the context of the different systems.
Physical examination Your assessment and examination skills will develop with experience, and following a systematic, structured approach will prevent you from missing important details. Begin your observations as soon as you see the patient (Epstein et al., 2003), by watching them as they get out of the chair to walk. This will provide invaluable information. Your patients may not be aware that you are observing them at this point, but their general demeanour will indicate the severity of their symptoms. Consider the following: • Does the patient look ill or in pain? • Can the patient walk or weight bear? • Is the patient using a walking aid? • Is the patient guarding anywhere? The recommended systematic, structured approach for physical examination of the musculoskeletal system is Look–Feel–Move, which follows the sequence described below (Bickley, 2007): Look (inspection): look at the whole patient before focusing on the chief complaint. Always compare with the contralateral limb. Look at the joint above and below. Look for muscle wasting, scars or redness, symmetry and alignment and bony deformities. Feel (palpation): feel the joint or limb for heat, fluid, bony landmarks, nodules, soft tissue tenderness, and crepitus (the popping or cracking noise heard in the knee joint on movement, usually heard when the knee is bent and then straightened). Again compare it with the opposite limb. Move (movement): test for range of movement (see below).
Range of movement (ROM) It is important to understand the normal range of movement for the specific
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Mary Drodz and Gail Parsons joint that is being assessed (Parvizi, 2006), bearing in mind that each type of joint has its own range of movement. The two ends of the goniometer are placed along the proximal and distal bones adjacent to the joint, and an average of three measurements is taken. Both active and passive movements are assessed, but it is essential for the patient to attempt active movements first. Then the practitioner performs passive movements while observing the patient’s facial expressions. The following movements are commonly tested: • Flexion and extension (bending and straightening). • Abduction and adduction (moving away from the midline and moving towards the midline). • Pronation and supination (wrist). • Circumduction (circular movements) (of the shoulder). • External and internal rotation (hip or shoulder). • Dorsiflexion and plantar flexion (ankle). • Eversion and inversion (foot).
Pain assessment Pain is the commonest musculoskeletal symptom, but establishing the type of pain is important. According to Magee (2006) these are: • Dull, gnawing pain – suggests arthritic pain. • Sharp pain – indicates damage to a ligament or tendon. • Deep, boring and localised pain – tends to be bone pain. • Diffuse, aching and poorly localised pain that may be referred to other areas of the body – often signifies a vascular origin. • Dull, aching and hard to localise – usually indicates muscle pain. The acronym P Q R S T can be used as a useful aid to characterise the pain and for symptom analysis: P Palliation – what makes the pain better or worse? Q Quality of the pain – is it sharp or dull in nature? R Radiation – does the pain radiate anywhere? S Severity – a valid and reliable pain scoring system is beneficial, with pain scored both at rest and with movement. T Timing – when is the pain at its worst? In the morning, after movement, after sitting or at night?
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Exercise 8.4 Use the PQRST acronym with respect to a recent assessment you have carried out. Were you aware of your visual assessment when the patient was standing or walking?
Joint examination In addition to testing range of motion as described previously, each joint should be examined for the following: Swelling: this may be localised to one joint or more generalised to the whole limb. Stiffness: affecting one or more joints. Deformities: these might include bow legs (genu varus), knock knee (genu valgus), kyphosis or ulnar deviation. Muscle weakness: muscle wastage may occur as a result of underuse. Changed sensation due to neurological changes: pressure on a nerve can lead to paraesthesia or numbness. Loss of function of the joint: this means the usual range of movement is not achievable. Crepitus: this grating sound within the joint occurs on movement.
GALS assessment All patients should receive a GALS assessment. This involves examination of the patient’s gait, arms, legs, and spine, hence GALS. It is a quick assessment to carry out and it acts as a screening tool for musculoskeletal problems (Arthritis Research Campaign, 2005). The GALS screening questions are as listed below: Have you any pain or stiffness in your muscles, joints or back? Can you dress yourself completely without any difficulty? Can you walk up and down stairs without any difficulty? If the patient has no stiffness, no difficulty with dressing, or with climbing
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Mary Drodz and Gail Parsons stairs, they are unlikely to be suffering from any significant musculoskeletal disorder. Otherwise, the examination is broken down into four areas, focusing on gait, arms, legs and spine. Gait: Gait guides the diagnosis. It can be observed while patients are unaware, as they walk into the consulting room or into the clinic cubicle. The most common types of abnormal gait are Trendelenburg gait and antalgic gait. Trendelenburg gait is a ‘duck-like’ walk that reflects unilateral weakness of gluteus medius muscle. Antalgic gait is a one-sided limp, whereby the patient takes quick, soft steps to shorten the period of weight bearing on the involved extremity. It is a reflex response to weight bearing on a painful limb. Arms: Ask patients to put their arms behind their head, to assess the glenohumeral, sternoclavicular and acromioclavicular joints. Then they should put their arms out straight so you can check for full elbow extension. If they put their hands out to the front you can assess any wrist or finger swelling or deformity. Check, too, whether their fingers extend fully. Ask them to turn their hands over to test supination and pronation, and to see if the palms are normal, of if there is any swelling, wasting or erythema. You can assess grip power if they make a fist, and assess the precision of their pinch and dexterity if they pinch their finger to their thumb. Legs: First, inspect the patient while he or she is standing. Then check for quadriceps bulk and symmetry, any knee swelling or deformity, or anomalies of the forefoot, midfoot and arches. Then, examine the patient while lying down. Flex the hip with knee flexed. Is there any crepitus or limitation? Passively internally rotate each hip in flexion. Is there any pain or restriction? Press on the patella. Is there any patellofemoral tenderness, knee effusion, or evidence of synovitis? Also inspect the soles of the feet for abnormal callosities. Is there any evidence of abnormal weight bearing? See Fig. 8.1. Spine: It is usual before examining the spine to take a full history of any injury. Begin your inspection while the patient is standing using the approach of Bulstrode and Swales (2007). While both standing inspect the patient from behind. Is the muscle bulk normal and symmetrical? Is the spine straight? Then inspect the standing patient from the side. Is there normal lordosis? Is there evidence of kyphosis? Inspect the patient as he or she bends over to touch toes. Is the flexion of the lumbar spine
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Fig. 8.1 Knee examination normal? If you press over the midpoint of the supraspinatus, is there any hyperalgesia or fibromyalgia? Now observe the standing patient from the front. When the head is tilted towards shoulders, is there normal lateral neck flexion? A more indepth musculoskeletal assessment is required for patients with specific musculoskeletal complaints, and the patient’s joint above and below the affected area must be assessed.
Other investigations There are a number of tests that can be performed to aid diagnosis and differential diagnosis. X-ray: Plain X-rays should be taken of the areas above and below the problem area. Anteroposterior and lateral views are usually necessary. Magnetic resonance imaging (MRI): This is used if the soft tissues are thought to be involved. Bone scan: This rules out sinister pathology or bone infection.
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Mary Drodz and Gail Parsons DEXA scan: This is the gold standard for diagnosing osteoporosis. Nerve conduction studies: These measure how well individual nerves send electrical signals from the spinal cord to the muscles, and can be used to help diagnose nerve problems. Arthroscopy: This is used to see within a joint such as knee, shoulder, ankle. Synovial fluid analysis: This distinguishes between inflammatory and non-inflammatory conditions, and provides direct evidence of an infection or haemarthrosis. Blood tests: These include full blood count, erythrocyte sedimentation rate, C-reactive protein, bone profile (calcium and alkaline phosphatase), uric acid, rheumatoid factor and blood cultures. Joint aspirate: Analysis of fluid drawn from a joint can diagnose infection, bleeding into the joint, or arthritis. Urinalysis: This non-invasive test will reveal any substance that is not normally found in urine, such as blood or protein (indicates infection).
Exercise 8.5 Identify why and when the listed diagnostic tests would be carried out and how their results might be useful to aid diagnosis.
Patient management and monitoring Most treatment plans are coordinated with respect to the individual patient’s needs and it is important to ensure that family and carers are included in any plans. Various assessment tools can be used to provide a baseline scoring system. They can then be used again following an intervention to identify any improvement or deterioration in the patient’s condition.
Numerous valid and reliable assessment tools for all joints of the body are available at http/www.orthopaedicscores.com
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Assessment of patients with musculoskeletal pain The Patient Related Outcome Measures (PROMS) are being used currently for total, knee, hip and ankle replacements pre and post operatively, but there are many tools in current use, including the following: • Oxford hip score. • Oxford knee score. • Harris hip score. • Womac score. • Pain assessment tools. • Neurovascular tests (colour, sensation, movement, nerve sensitivity, motor control, skin warmth to indicate circulatory problems and capillary refill time to check dehydration and peripheral perfusion). • Medical Research Council (MRC) muscle strength score.
Exercise 8.6 Review two of the assessment tools listed here and identify one that would be of use to you in your area of practice.
Conclusion Musculoskeletal assessment requires a thorough systematic examination of the patient based on a sound knowledge of the functional anatomy and an accurate patient history, as well as diligent observation.
References and further reading Arthritis Research Campaign (2005). Clinical Assessment of the Musculoskeletal System. A Handbook for Medical Students. Derbyshire: Arthritis Research Campaign. Bickley, L.S. (2007). Bates’ Pocket Guide to Physical Examination and History Taking. Philadelphia: Lippincott, Williams and Wilkins. Bulstrode, C. and Swales, C. (2007). The Musculoskeletal System at a Glance. Oxford: Blackwell. Dolan, B. and Holt, L. (2000). Accident and Emergency. Theory into Practice. London: Bailliere Tindall.
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Mary Drodz and Gail Parsons Epstein, O., Perkin, G.D., Cookson, J. and de Bono, D.P. (2003). Clinical Examination. London: Mosby. Magee, D.J. (2006). Orthopaedic Physical Assessment, 3rd edn. St Louis: Saunders. Parvizi, J. (2006). Orthopaedic Examination Made Easy. London: Churchill Livingstone.
Useful web resources Arthritis Care www.arthritisresearchuk.org
Health and Safety Executive www.hse.gov.uk
NHS Evidence www.evidence.nhs.uk
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Chapter 9
Assessment of patients with multiple sclerosis Amanda Andrews and Sue Lillyman
Key areas Common onset symptoms leading to a diagnosis of multiple sclerosis Assessment of the neurological system Confirming diagnosis of multiple sclerosis Mental status and motor and sensory function Patient management
Introduction With the increasing incidence of chronic disease and the ever-growing number of people living with long-term conditions, it is imperative that nurses assess their patients and develop their knowledge of presenting conditions. This chapter provides an overview of knowledge about multiple sclerosis (MS). In order for you to complete a holistic assessment and develop a care plan for a patient with MS, you need to establish the facts, the aetiology and pathology of the condition. This needs to be completed before being able to confidently treat and care for this client group and encourage self-management where appropriate.
Aetiology and epidemiology Multiple sclerosis is the most common cause of disability with a neurological basis in young adults. It predominantly affects adults aged between 20 and 45 years of age, both male and female. Figures from 2002 suggest that
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Amanda Andrews and Sue Lillyman approximately 2.5 million people worldwide have multiple sclerosis, of whom 62,000 can be found within the UK (Compston and Coles, 2002). It is unclear when the first case was diagnosed (an unconfirmed case was reported in 1396 in a saint who was born in Holland), but the first confirmed case was described over 150 years ago in 1838 by Robert Carswell whose work led to clinical description of the disease (Burgess, 2002). Within the last half century there has been an increasing understanding of multiple sclerosis and although it is incomplete, it does allow for accurate diagnosis. The precise causes are still unclear despite an extraordinary amount of research into the subject. The use of epidemiological data has aided our understanding about the disease. It is known to affect 1 in 1,000 people in the USA, Europe and Australia, and is generally more common in women and white people (McDonald, 1998). As the cause of multiple sclerosis is unknown, all information that is collected, including presenting symptoms, genetics and epidemiological data, are being constantly analysed in an attempt to determine a finite cause.
Neurological and autoimmune basis Multiple sclerosis is a neurological condition that affects the central nervous system, which consists of the brain and the spinal cord, in addition to twelve pairs of cranial nerves and thirty-one pairs of spinal nerves. The job of these nerves is to send electrical and chemical messages around the body to control the bodily functions of movement, vision and pain perception, among others, comprising both sensory and motor elements. The nerve networks in the brain are made up of grey and white matter. The grey matter consists of cell bodies (neurons) and the white matter consists of the nerve fibres (axons). Messages travel at extreme speeds along the nerve fibres to enable the brain to respond appropriately, and each nerve fibre has a fatty coating – a myelin sheath – which allows the smooth and effective transmission of the messages (Fig. 9.1). In both the brain and the spinal cord, this myelin is produced by specialised cells called oligodendrocytes. The body’s immune system protects us from viruses and bacteria. Immune cells fight infections by destroying invading microbes, but these can be harmful if they pass into the central nervous system. The central nervous system has a special protective mechanism involving so-called ‘tight junctions’ between certain cells, and these form what is known as the blood–brain
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Assessment of patients with multiple sclerosis barrier. This barrier allows useful products into the nervous system, such as glucose, but stops the passage of harmful substances and immune cells that are potentially harmful. When multiple sclerosis is in an ‘active’ phase (that is, detectable) it is thought that the blood–brain barrier has become damaged and an autoimmune response has ensued. Activated immune cells have seeped into the central nervous system and attacked ‘healthy’ or ‘useful’ nervous tissue, which they mistakenly regard as foreign material. For example, activated lymphocytes may attack the myelin sheaths around nerve axons, resulting in inflammation, and resulting in the blockage of messages along the nerve axon, and producing variable symptoms during a relapse.
Figure 9.1 Neuron These attacks on the sheath result in demyelination, and lead to permanent damage, causing varying levels of disability, depending on which axons are affected. For example, if inflammation occurs along the axon of the optic nerve, the patient will experience blurred vision or pain. The immune cells may cause different problems, but they all involve inflammation, cell death and erosion of the myelin sheath – the typical lesions of the disease – and this is the extent of our current understanding of the central nervous system in multiple sclerosis.
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Diagnostic considerations Inclusive features In current practice, the following are considered to be inclusive factors of the diagnosis of multiple sclerosis. Unfortunately, they are not conclusive. • Young adult age. • Gender and race (predominantly female sex and white race). • The place the patient lived for the first 15 years of life (there appears to be some evidence that if this is in the northern hemisphere, you are more susceptible). • Environmental triggers (e.g. emotional stress, infection or trauma) in individuals with predisposing factors (age 20–40 years, female, white race). • The patient’s location in terms of distance from the equator (the further away, the greater the risk). • Genetic factors. Usually patients suffer relative periods of good health alternating with worsening symptoms.
Diagnostic accuracy As the cause is unknown, the disease profile is unpredictable, which makes coping with the symptoms a major hurdle for people with multiple sclerosis. Affected individuals deal on a daily basis with uncertain and unstable symptoms coupled with an unknown future, and this unpredictability leads to very individual symptoms, making every individual’s multiple sclerosis profile unique. In 2001, the McDonald criteria were developed to establish guidelines for accurate diagnosis of multiple sclerosis (McDonald et al., 2001). Within these criteria, the following general points are recommended: • The diagnosis should be made by an experienced clinician with expert knowledge of multiple sclerosis and similar neurological conditions. • The prior probability that the individual has multiple sclerosis depends on factors such as age, ethnicity and geographical location. • Objective evidence of dissemination in time and space of lesions typical of multiple sclerosis is mandatory, as is the exclusion of other better explanations for the clinical features. • Historical reports of symptoms may suggest previous episodes of
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Assessment of patients with multiple sclerosis demyelination, but cannot be used without objective evidence to satisfy the requirement of lesions disseminated in time and space. • Multiple sclerosis can be diagnosed on purely clinical evidence of lesions separated in time and space. • Radiological (MRI) and laboratory evidence is desirable and may be essential where clinical evidence is insufficient for a secure diagnosis. • The choice of investigation will be determined by the clinical situation – for example, a delayed visual evoked potential is of value in a person with a spinal cord lesion but is of little value in a person with optic neuritis. • MRI is less useful in older people and in other inflammatory conditions such as acute encephalomyelitis where its specificity is lower. MRI is not applicable in people with metallic foreign bodies, pacemakers, etc., or in those who cannot tolerate the procedure. These guidelines are supported within the NICE guidelines entitled Management of Multiple Sclerosis in Primary and Secondary Care (National Institute for Health and Clinical Excellence, 2003). Within these guidelines, rapid diagnosis is one of the key priorities. It is recommended that a rapid consultation should take place no longer than 6 weeks from referral to a neurologist. The use of such guidelines can only be beneficial to patients who are anxiously awaiting a diagnosis.
Disease profile and types At the time of diagnosis it is almost impossible to determine what type of disease the patient has, or determine the pathway their condition is likely to follow. Multiple sclerosis is a very unique and individualised condition and only over time can predictions be made, based on the patient’s symptoms and relapse profile. Throughout the literature, the types of multiple sclerosis take on many different titles. However, overall the main three types are relapsing– remitting multiple sclerosis, secondary progressive multiple sclerosis, and primary progressive multiple sclerosis. Relapsing–remitting multiple sclerosis (RRMS): This is the most common form and is the pattern most people follow after diagnosis. It is defined by evidence of relapses in the condition and recovery periods. A relapse is defined as ‘The development of new symptoms or the reoccurrence of old symptoms that last at least 48 hours’ (Burgess, 2002). To be classified as RRMS, the patient must show signs of clearly defined relapses and some
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Amanda Andrews and Sue Lillyman amount of recovery. The recovery profile will, like the condition itself, vary from patient to patient, with most making an almost complete recovery. Patients may be left with some residual symptoms like fatigue and pain. Secondary progressive multiple sclerosis: This form of multiple sclerosis often follows RRMS, but it has fewer relapses and a continuous loss of function and the ability to recover from relapses decreases. Again it is unpredictable, and the rate of disability varies from patient to patient, but often there is a gradual progression. Approximately 60% of people with multiple sclerosis have this form of the disease (Conference Report, 1999) and 50% of people with RRMS go onto develop it. There is a ‘transition phase’ in which a patient moves into secondary progressive multiple sclerosis from RRMS. During this time, many patients feel increased levels of anxiety and fear about a once-again uncertain future (Burgess, 2002). Primary progressive multiple sclerosis: As the title suggests, this type of multiple sclerosis is progressive from the onset, with no relapses. Over the years, there is continual loss of physical and cognitive function. The Conference Report (1999) suggested that at any given time approximately 20% of the multiple sclerosis population suffers from the primary progressive form of the disease. As one can imagine this is a very aggressive condition and it is very difficult both to manage and to accept.
Symptoms Patients with multiple sclerosis will have symptoms that vary, depending where the inflammation has occurred in the brain or spinal column and the location of the damaged myelin sheath or axon. Symptoms include: • Pain. • Fatigue. • Spasticity. • Bladder and bowel dysfunction (incontinence and constipation). • Sexual dysfunction. • Poor or reduced mobility. • Blurred vision. • Vertigo and dizziness. • Reduced peripheral sensations. • Cognitive impairment. • Depression.
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Exercise 9.1 List the most commonly experienced symptoms you have noticed in patients with multiple sclerosis. How do they compare with the symptoms listed here?
Assessment procedure Whenever a neurological assessment is conducted it should follow a methodological approach, working from the highest level of neurological function (e.g. mental status) down to the lowest level (e.g. reflexes) (Crouch and Meurier, 2005), so that the examination covers mental status, cranial nerves, motor system, sensory system and reflexes.
Mental status In the assessment of mental status, look for the following signs and symptoms: • Headache. • Dizziness and disorientation. • Change in mood, attention span or speech ability. • Level of consciousness (altered or loss of). • Muscle weakness or paralysis. • Skin numbness or altered loss of sensation. • Physical appearance and behaviour. • Cognitive function.
Cranial nerve function In the assessment of the cranial nerves, you need to know their function. These are shown in Table 9.1.
Case Study 9.1 Mrs S a 30-year-old white woman who complains of being very tired in the afternoon. She sometimes loses her balance and has fallen down recently. She
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Amanda Andrews and Sue Lillyman complains that her eyes feel funny and her children have commented that they sometimes ‘move funny’. She says that sometimes she sees ‘double’ and a year ago she lost sight in one eye but it returned. She complains of muscle spasms in her legs which are worse in the summertime and heat. Her husband teases her sometimes as her speech is slurred even when she has not had a drink, but this is only when she is tired. She also notices that she cannot concentrate well and has mood swings that she never had before. She has no pain and no incontinence although she always feels she wants to go to the toilet.
Table 9.1 Sensory and motor function of the cranial nerves
Cranial nerve
Type of impulse Function
Olfactory
Sensory
Smell (from nasal mucous membrane)
Optic
Sensory
Vision
Occulomotor
Motor
Constriction of pupils and elevation of eyelids
Trochlear
Motor
Eye movements
Trigeminal
Sensory
Pain, touch and temperature sensations from cornea, nasal and oral mucosa and facial skin
Motor
Jaw motion (e.g. clenching, biting, chewing)
Abducens
Motor
Lateral eye movements
Facial
Motor
Facial expressions (smiling, frowning, closing eyes)
Sensory
Sensation of taste on anterior two-thirds of tongue and stimulation of secretions from salivary glands
Vestibulocochlear
Sensory
Hearing and balance
Glossopharyngeal
Sensory
Taste sensation on posterior third of tongue, gag reflex of pharynx when stimulated, and salivating
Motor
Swallowing
Sensory
Sensations in throat, larynx, heart, lungs, bronchi, gastrointestinal tract and production of digestive juices
Motor
Swallowing and talking
Vagus
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Accessory (spinal)
Motor
Movement of shoulders, head and larynx via sternocleidomastoid, neck muscles and upper portion of the trapezius
Hypoglossal
Motor
Tongue movements
Exercise 9.2 What might lead you to a diagnosis of multiple sclerosis for Mrs S in Case Study 9.1? Which cranial nerve seems to be involved?
Motor function When assessing the motor functions the following should be taken into account and recorded: • Body position. • Muscle tone and strength. • Cerebellar function using the Romberg test to check cerebellar function (the test is positive if patients lose balance when they stand with their feet together, hands at their sides and their eyes closed).
Sensory function When assessing the sensory functions, consider the following: • Response to pain. • Position of limbs. • Sensitivity to vibration. • Light touch sensation. • Discrimination. • Check reflexes.
COLDSPA examination This approach by Weber and Kelley (2007) is a systematic way of collecting data during patient assessment, without omitting important items, which can be related to symptoms of their condition.
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Amanda Andrews and Sue Lillyman Table 9.2 The COLDSPA examination
C Character of the sign or symptom. O Onset of the illness or the complaint. L
Location of the complaint (if related to pain, is it localised or radiating?).
D Duration of the symptom (be specific about time and date of onset). S Severity of the symptom. P Pattern (what makes the symptom worse or better, is it affected by the weather, the time of day, or position, and does anything relieve it, such as medication, heat or rest?). A Associated factors (what other symptoms occur at the same time as the primary symptom, and are other body systems affected?).
Patient management The management of symptoms in people with multiple sclerosis is difficult because they are ever-changing and have varying severity. Ongoing assessment is particularly important, therefore, for this patient group. The NICE guidelines for multiple sclerosis management go some way to aid in the management of symptoms, as do the patients’ own coping mechanisms and support networks (National Institute for Health and Clinical Excellence, 2003).
Disease-modifying therapies The kind of medication available to people with multiple sclerosis are diseasemodifying therapies (DMTs). They are only available to a limited number of patients as very strict criteria are applied to their use, thus ensuring that they are only given to patients who would benefit from them. Two current DMTs are glatiramer acetate (Copaxone™) and interferon beta (Avonex™, Betaferon™ and Rebif™). Glatiramer acetate is indicated for the treatment of RRMS. It is a basic protein that binds with human antigens to aid suppression of the immune system and reduce attacks on healthy myelin. Interferons are also proteins. They are produced within the human body and are a type of cytokine, with an important role in the production of antibodies and thus an essential part of the immune system. All interferons have the ability to regulate the immune system and they play an important role in protecting against intruders including viruses. One negative effect of enhancing antibodies
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Assessment of patients with multiple sclerosis is the neutralising effect they have on the activity of the drug, which can then reduce its efficacy (UK Multiple Sclerosis Specialist Nurse Association, 2002). Unfortunately, both medications have to be injected by the patient. They cannot be ingested as they are proteins and will be digested in the stomach. These injections are an additional complication for some patients; however uncertainty about their condition means that many patients will ‘try anything’ and are willing to try the medication. Both medications are still being closely monitored and research continues into their precise effects on the profile and progress of the disease.
For further information on treatment of patients with multiple sclerosis, see www.nhs.uk/conditions/Multiple-sclerosis/Pages/Treatment.aspx.
Conclusion Multiple sclerosis is a neurological condition with no confirmed cause and no cure. It is progressive in nature and unique to the person experiencing it. There are a number of common symptoms, which present according to the type and level of disability. Symptom management is the main focus of management, and disease modifying therapies are used to aid management of the condition. Specialist nurses, consultants and professionals allied to medicine must work closely together to support patients with multiple sclerosis and improve their quality of life.
References and further reading Burgess, M. (2002). Multiple Sclerosis. Theory and Practice for Nurses. London: Whurr Publications. Compston, A. and Coles, A. (2002). Multiple sclerosis. Lancet 359, 1221–1231. Conference Report (1999). Management of neurodegenerative disorders. Hospital Medicine 60(7), 1221–1231. Crouch, A. and Meurier, C. (2005). Health Assessment. Vital Notes for Nurses. Oxford: Blackwell. McDonald, W.I. (1998). Diagnostic methods and investigations. In: A. Compston, G. Ebers and H. Lassmann (eds) McAlpine’s Multiple Sclerosis. London: Churchill Livingstone. McDonald, W.I., Compston, A. and Edan, G. (2001). Recommended diagnostic criteria for multiple sclerosis Annals of Neurology, 50, 121–127.
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Amanda Andrews and Sue Lillyman National Institute for Health and Clinical Excellence (2003). Management of Multiple Sclerosis in Primary and Secondary Care. Clinical Guideline 8. London: NICE. UK Multiple Sclerosis Specialist Nurse Association (2002). The UK Multiple Sclerosis Clinical Management Manual. Care Across the Disease Trajectory. Serono: Sage. Weber, J. and Kelley, J. (2007). Health Assessment in Nursing. New York: Lippincott, Williams and Wilkins.
Useful web resources Multiple Sclerosis Society www.mssociety.org.uk
Multiple Sclerosis Support (from other people with multiple sclerosis) www.multiplesclerosissupport.org
Multiple Sclerosis Trust www.mstrust.org.uk
National Prescribing Centre Information www.npci.org.uk
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Index Action in Diabetes and Vascular Disease (ADVANCE) 90 Action to Control Cardiovascular Risk in Diabetes (ACCORD) 90 Activities of Daily Living 40, 66 advanced assessment skills 27 advanced practice development 12 alcohol 82 anatomical position 103 antalgic gait 108 assessment models 36 assessment, types of 35 assistive technology 20 asthma 63 auscultation 66 autoimmune response 115 Beck Depression Inventory 77 blood-brain barrier 14–115 Borg scale 64 bronchitis 63 cardiovascular conditions, prevalence of 71 care needs 2 case management 5, 17 central nervous system 114 Charcot’s foot 92, 93 chest examination 64 chronic obstructive pulmonary disease 63 cognitive state 77 COLDSPA examination 121, 122 communication 78 coronary heart disease 71 cranial nerve function 119, 120, 121 Cushing’s syndrome 88 depression 77 determinants of health 50 diabetes mellitus 87—99 abdominal examination 92 aims of care 94 care planning 95 clinical examination 92 foot examination 93 incidence of 87 neurological examination 94
NICE guidelines for 89 patient education 96, 98 psychological and behavioural assessment 94 treatment options 95 types of 88 vascular examination 92 differential diagnosis 68, 109 digital TV 21 education framework 4 emphysema 63 exercise 82 family history 67 fluid status 76 GAD-7 Anxiety Screening Tool 77 GALS (gait, arms, legs, spine) assessment 107, 108 healthcare needs 50 Health Care Systems Model 41 health-promoting self-care system 38 heart, structure and function of 73 heart failure 71–83 aetiology of 72 definition of 74 epidemiology of 72 medications for 78, 79 patient management 78 symptoms of 74 Heron’s six-category analysis model 55 history-taking 49—57, 75, 91, 103 checklist for 54 principles of 51 Hospital Anxiety Depression Tool 77 immune system 114 individual budgets 23 information technology 23 initial assessment models 36 initial interview 60, 62 inspection 65, 105 integrated care pathways 34, 35 interview skills 53 investigations of heart failure 75 investigations of respiratory problems 66 joint examination 107
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Knowledge and Skills Framework 28 learning contract 9 lifestyle 81 long-term conditions 1 generic model for 3 Maslow’s hierarchy of needs 38 Medical Research Council Dyspnoea Scale 64 mental status 119 multiple sclerosis 113—123 aetiology of 113 diagnosis of 116 epidemiology of 113 management of 122 primary progressive 118 relapsing-remitting 117 secondary progressive 118 symptoms of 118 therapies 122 types of 117 musculoskeletal pain 101—111 assessment tools 110, 111 investigations 109 patient management 110 physical examination 105 myelin 114 national service frameworks 19, 89 needs analysis 13 needs assessment 50 Neighbour’s Consultation Model 42 neurological assessment 119 neuron 115 New York Heart Association Classification 75, 76 NHS Direct 21 Nottingham Health Profile 44 nursing assessments 31 nursing process 37 nutritional status 78 objective data 32 oedema 76, 77 Orem, Dorothea 38
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pain assessment 106 palpation 65, 105 patient experience programme 21 payment by results 21 Pendleton’s Consultation Model 43, 97 percussion 65 personalised care plan 35 Pharmaceutical Services Negotiating Committee 22 pharmacy contract 22 PQRST acronym 106 practice-based commissioning 19 psychological therapies 77 Quality and Outcomes Framework 23 quality of life indicators 36, 44, 66, 75 range of movement (ROM) 105 reflective journal 5, 7 reflective practice, value of 8 respiratory disease 59–69 exacerbations of 69 medications for 68 respiratory symptoms 60 Romberg test 121 Roy’s Adaptation Model 39 self-assessment 3 self-directed care 23 SF-36 Health Survey 32, 44, 75 single assessment process 24 Six-Minute Walk Test 75, 76 smoking 81 SOAPIE model 56 social history 67 SOCRATES assessment 57 subjective data 32 skills 11 tachycardia 76, 77 telecare 20 telemedicine 20 Trendelenburg gait 108
