Interdisciplinary Team Approach for Asthma - Essay Example

Interdisciplinary Team Approach for Asthma Introduction While most of the common medical ailments can be managed by a family physician, many conditions need extensive collaboration between professionals within the medical fraternity and also from other experts. Such a management of a patient is known as multidisciplinary or interdisciplinary approach. In this essay, a multidisciplinary team management of an adult with moderate acute asthma attack admitted to adult ward will be elaborated to ascertain the importance of team approach in managing adult repiratory disorders. The team members whose roles will be discussed in this essay are physician, nurse and parents. The Client 20 year old James, an engineering student, was admitted to the adult ward with complaints of cough, chest tightness, wheezing since one day and difficulty in breathing since 2 hours. Prior to the onset of these symptoms he suffered from running nose for a couple of days. He had no fever, vomiting or abdominal pain. The cough was worse in the nights and in the early morning. Exercise and exposure to cold increased the cough. On further enquiry into the past history, the patient complained that he suffered from repeated attacks of cough and chest tightness on and off since 6 months, especially when he had running nose or was exposed to cold environment. Since the symptoms were not severe, James did not see a doctor then for those symptoms. However, breathlessness in the current episode made him come to the hospital. James was a smoker and smokes about 3-4 cigarrettes a day. He consumes alcohol occasionally. He did not have hypertension or diabetes. He had no known allergies. His father is a known patient of asthma. On examination, James was alert and oriented to time, place and person. He was finding it difficult to talk continuously. He preferred to sit and talk and avoided lying down. He had no cyanosis or peripheral edema. He appeared mildly pale. Respiratory rate was 25 per minute, pulse rate was 100 per minute, temperature normal, blood pressue 130/80mmHg. Auscultation of the chest revealed presence of breath sounds bilaterally with prolonged expiration. Rhonchi were heard in the basal areas of the chest. Occasional crepitations were also heard. Saturations were 90 percent. Examination of the other systems was unremarkable. In view of the severity of the condition and low saturations on pulse oximetry, James was admitted to the adult ward for further, evaluation, observation and managment. James was accompanied by his parents. The disease in the client Reversible obstruction of the airways due to chronic inflammation and bronchial hyper-reactivity is known as asthma. Asthma is a common repiratory condition that affects people of all ages and sexes irrespecitve of region and race. This condition affects about 300 million people in the world including children (Sharma and Gupta, 2009). It consitutes of approximately 2 percent of all emergency department visits. The condition is characterised by paroxysmal narrowing of the bronchial airways due to inflammation of the bronchi and also due to spasm of the bronchi due to contraction of the bronchial smooth muscle. Most of the patients develop symptoms in early childhood. 80-90 percent of them experience symptoms before 6 years of age. But, the clinical presentation can occur at any age. If left unattended and in the presence of severe symptoms, asthma can contribute to morbidity and mortality. The most common symptoms of asthma are wheezing, cough, nocturnal or exercise-induced cough, breathlessness, tightness of chest and sputum production (Brenner, 2009). The symptoms may be perineal or seasonal, continuous or intermittent, or during the day or night. Some of the precipitating or aggravating factors include viral infections, intense emotions, environmental irritants, exercise, pets or carpets at home, drugs like aspirin, additive foods, weather changes, stress and certain diseases like gastrointestinal reflux, sinusitis and rhinitis (Brenner, 2009). Many patients have a family history of asthma or other allergy conditions. To arrive at a diagnosis of asthma, physicians must establish episodic airflow obstruction symptoms which are reversible and alternative diagnoses must be excluded (Brenner, 2009). There are no specific tests to arrive at a diagnosis of asthma. Pulmonary function tests are useful to monitor response to treatment (Brenner, 2009). Treatment depends on the staging of asthma which again depends on the frequency and severity of symptoms. The main drugs for treatment are bronchodilators and steroids. These drugs can be given either oral, through metered dose inhalers or through nebulisations (Sharma and Gupta, 2009). Education of the patients is very important in the management of asthma. Parents, patients, partners, friends, relative and caregivers need to learn to identify symptoms and signs of asthma, what medications to given at home and when to bring the patient to the hospital. Any environmental factors which trigger attacks of asthma must be avoided (Sharma and Gupta, 2009). Management of asthma in the client The acute attack of asthma in James was managed through an interdisciplinary team approach with patient as the center and physician, nurse and parents as contributors of health care. 1. Role of doctor/physician The physician established the diagnosis of asthma and admitted the patient in the ward. Features of asthma in James were cough, breathlessness, wheezing and tightness of chest and bilateral rhonchi in the lungs. Also, alternative explanation features were lacking. Significant smoking history, voice disturbance, cardiac disease, chronic productive cough, prominent dizziness, peripheral tingling and light-headedness indicate lower probablity of asthma (SIGN, 2008). Since James had high probability of asthma, trial of treatment was initiated. The peak expiratory flow rate was was 50 percent. The physician ordered the nurses to start James on 100 percent oxygen through mask. Along with oxygen, salbutamol nebulisation on 1 ml solution in 2.5 ml of saline was ordered. The physician also wrote orders for Injection hydrocortisone 100 mg every 6 hours through intravenous route. No blood investigations were done. Even chest X-ray was not asked for as the physician was confident of the diagnosis of asthma. Within one hour of therapy, the physician reassessed the clinical condition of the patient. James whose respiratory rate was 25 per minute and who could not talk in sentences told the doctor that he felt much better. The respiratory rate decreased to 20 per minute and the saturations shot up to 2 percent. James could talk more comfortably in sentences. The physician ordered the nurses to decrease oxygen flow to 50 percent. On examination, James continued to have severe rhonchi and this prompted the physician to add ipratropium bromide along with salbutamol nebulisation. Research has shown that combining anticholinergics with beta-2 agonist leads to better bronchidilatation than beta 2 agonists alone (SIGN, 2008) The dose of ipratropim that was added was 0.5 mg every 4 hours. The physician wrote orders for hourly vital signs and saturations monitoring and to inform him in case of any decline in the clinical situation. Repeat PEFR after 4 hours showed an improvement to 60 percent which was informed to the physican who asked to continue the same treatment for the next 12 hours. 2. Role of nurses Nurses taking care of James played a major role in the managment of asthma in James. As such nurses play an important role in the promotion of health of an individual because of their direct contact with their patients and due to their proximity with them. During the course of contact with any patients, nurses observe 3 main roles which are practitioner, leader and researcher. As a practitioners, nurses attend to all the medical needs of the patient (Nettina, 2006). In James, the medical needs are to gain control of symptoms, improve the feeling of wellness, increase oxygenation of the tissues of his body and decrease his anxiety and also that of his parents. To attend to these needs, the nurses discussed with the physicians and provided appropriate interventions in the form of dual-drug nebulisations, oxygen therapy and intravenous steroids. They monitored the patient regularly, every hour to ascertain response to treatment. They checked PEFR every four hours to gain confidence about response to treatment. Any decline in the clinical condition of the patient was informed to the physician. Salbutamol nebulisation causes some side effects like tremors and tachycardia (Chin, 2009). The nurses monitored the patient for these side effects and decreased the dose of next nebulisation whenever these symptoms were seen. The nurses maintained cleanliness and hygiene of the nebulisation apparatus and the oxygen mask and took all aspectic precautions for the same. As a leaders, nurses take decisions which relate to, influence and facilitate the actions of others with an aim to achieve a particular goal (Nettina, 2006). Whenever, there was clinical deterioration in James, the nurse incharge would call the physican and seek advice about further managment. She would also provide valuable advice on the treatment that might be useful for the patient. As researchers, nurses aim to implement studies to determine the actual effects of nursing care and to work towards further improvement in nursing care (Nettina, 2006). Thus, the nurses gained insight into the benefits of adding anticholinergic drugs along with beta agonists in the treatment of acute asthma. The role of nursing is authenticated in helping people move towards independence in all activities of daily living (Nettina, 2006). After 24 hours of nebulisation therapy, the clinical condition of James improved dramatically and the nurses, in consultation with the physician and the parents planned to discharge James after another 24 hours. During this period, nebulisation was made 4th hourly, oxygen therapy was stopped and intravenous hydrocortisone was changed to oral prednisolone 40 mg twice a day. The team of physicians, nurses and parents discussed about continual of care at home and long term management of asthma. The nurses coordinated the activities of the team and participate actively within the team through continuous research and critical thinking. Like any other profession, nursing has a distinct body of evidence and extensive education involving both theory and practical components. All nurses share a common identity, attitudes, behaviors and values (Neal, 2007). There are four important principles underpinning the nurse-patient relationship. These include self-regulation, professional competence, teamwork and continuing professional development (Neal, 2007). The nurses reviewed the past history of James to ascertain the degree and frquency of symptoms to establish long term treatment. According to James, this was the first ever acute attack of asthma which required hospitalisation. His previous symptoms of cough were present since six months. The symptoms occured for about 3 to 6 times in a week. The flare-ups affected his daily exercise and he preferred not to walk up to the college canteen when he had the symptoms. He developed cough about 2 to 4 times in a month. He never visited a doctor for these symptoms and thus no PEFR test was ever done before. The symptoms were exaggerated in cold seasons and after upper respiratory tract infection. Based on these clinical features, a diagnosis of mild persistent asthma was made (Chin, 2009) and James was started on intermittent salbutamol metered dose inhaler therapy whenever he had symptoms. James was also told to take inhalation steroids twice a day during cold seasons as preventive measures. James was also advised to take salbutamol MDI at the onset of an acute attack. Another important health need which was taken care of by the nurses was anxiety. James and his parents were anxious about the acute asthmatic attack in James. The relationship between a nurse and a patient is of therapeutic nature and based on the provision of care, guidance and assistance of the patient (Neal, 2007). It is shaped mainly by four concepts namely, trust, power, intimacy and respect (Neal, 2007). Trust is a critical concept in the nurse-patient relationship because, the patient is in a vulnerable position and the patient places trust in the nurse as soon as he or she enters the health care setting. As such, illness makes an individual vulnerable and this is exaggerated in the presence of unfamiliar surrounding, relationships and situations. Trust in this relationship is largely based on the assumption of the fact that the nurses are skilled and knowledgeable and will excise these aspects in dealing with the patient. Trust in a nurse-patient relationship improves care and reduces stress. It was though establishment of trust that James could cooperate with treatment. Nursing is actually a social activity demanding the professionals to be socially competent. Thus interpersonal skills of communicating and relating are pivotal for the development of social competence of the nurses. Nurses need to spend time and listen to the needs of the patient and understand the experience of the patient. The central aim should be to 'initiate supportive interpersonal communication in order to understand the perceptions and needs of the others' (Reynolds and Scott, 1999; qtd. in Stein- Parbury, 2005). According to Benner et al, qualities that should be present in an experienced clinician are calculative reasoning, consulting research, analysis of particular situations and theoretical literature. The nursing profession has a self-regulation policy to serve the public. It has a 'Code of professional conduct' defined and all nurses must abide by this. The nursing midwifery council (NMC, 2002) registers only those with professional competence. It establishes from time to time training aspects, standards of education, conduct and performance for the nurses. The ultimate aim is to possess skills and abilities which allow the nurse to practice safely without supervision. Thus, the good interpersonal skills of nurses established a goof nurse-patient relation, nurse-physician relation, nurse-parent relation and nurse-nurse raltions, all contributing to the better care of the patient. Providing education to the patient : In case of James, due to the chronic nature and recurrence possibility of the state of disease, the parents, friends, relatives and the patient himself needed to educated about the nature of the disease, clinical symptoms, danger signs which warrant immediate medical attention and managment of symptoms at home. James was also advised to quit smoking. The education was imparted by nurses because of their interpersonal skills. Nursing theorists have considered interpersonal skills and personal attributes as integral to professional bonding. According to a study on the themes and variations of the nurse-patient relationship by Ramos (1991), relationships characterized by mutuality and reciprocity had the most intense levels of attachment. Professionally, nurses interact with a variety of people for various reasons and contexts. This requires effective interpersonal communication and good relation with other people. According to Rask and Brunt (2007), there are six categories of nurse-patient interactions which are: 'building and sustaining relationships', 'supportive/encouraging interactions', 'social skills training', 'reality orientation', 'reflective interactions' and 'practical skills training.' The nurses acted in acoordance with these principles of nurse-patient relationship to meet the health needs of the patient and also to ally anxiety in the patient and his family members. 3. Role of parents The role of parents and other family members in the managment of asthma is very critical. As advised by the physician, the parents coaxed James into stopping smoking and change his lifestyle. They maintained a dairy in which symptoms of James were recorded along with the treatment instituted. They brought this for follow-up every time they came for physician follow up. The parents also avoided any pets at home. Father, who is a smoker quit soking. The family avoided areas of pollution for travel. They took all measures to prevent dust at home. They changes the furniture, curtains and quilt to cotton material which are easily washable. In winter and autumn seasons they started James on preventive inhalation steroids. With these measures, James had no further attack of acute asthma. It is one year since his admission to the ward for acute attack and for the past 6 months he is symptoms free. Conclusion Effective management of clinical conditions like asthma is possible through only interdisciplinary team approach. While physicians examine the patients and provide an outline for clinical management, nurses take up the roles of practitioner, leader and researcher and institute treatment, assess the clinical condition of the patientt, monitor response to treatment and provide valuable suggestions to the physician. Nurses also provide education to the patients and their family memebers through interpersonal skills and development of trust. Parents who are with the patient all the time and who are aware of the symptoms and response to treatment of their son are in a position to give valuable information to the clinicans and also are able to stress the need to take proper treatment. Thus, asthma can be effectively managed through interdisciplinary approach. References Brenner, B.E. (2009). Asthma. Emedicine from WebMD. Retrieved on 8th November, 2009 from http://emedicine.medscape.com/article/806890-overview Chin, E.S. (2009). Pediatrics, Reactive Airway Disease. Emediicne from WebMD. Retrieved on 8th November, 2009 from http://emedicine.medscape.com/article/800119-overview National Centre for Health Outcomes Development (2002). Outcome Indictors for Asthma. Retrieved on 8th November, 2009 from http://nchod.uhce.ox.ac.uk/asthma.pdf Nursing & Midwifery Council 2002. The Code: Standards of conduct, performance and ethics for nurses and midwives London: NMC. Neal, K. (2007). Nurse-Patient relationships. Retrieved on 8th November, 2009 from http://www.nursing-practice.co.uk/docs/newCh5.pdf Nettina, S.M. (2006). Manual of Nursing Practice. (8th ed.). New York: Lippincott Williams & Wilkins. SIGN. (2008). British Guideline on the Managment of Asthma. Retrieved on 8th November, 2009 from http://www.sign.ac.uk/pdf/sign101.pdf Sharma, G.D. and Gupta, P. (2009). Asthma. Emedicine from WebMD. Retrieved on 8th November, 2009 from http://emedicine.medscape.com/article/1000997-overview Read More