Living with a Long Term, Multiple Pathology - Essay Example

?Long term condition: Asthma and Depression INTRODUCTION Long terms conditions are significant health issues which often severely compromise the health and the normal functions of individuals. For some patients, they may often suffer from multiple illnesses and these multiple pathologies usually exacerbate patient symptoms. This paper shall be a case study of a patient suffering from two long-term conditions. It shall discuss asthma and depression in patient Bruno. Asthma has now become prevalent in the UK with latest figures indicating that 5.4 million individuals suffering from the disease, 1.1 million being children and 4.3 being adults (Asthma UK, 2012). About 1,131 deaths were attributed to asthma in 2009, and 12 of these were less than 14 years of age (Asthma UK, 2012). For depression, it is considered the fourth leading cause of disability and disease in the world (NICE, 2011). In the UK, the prevalence of this disease in 2006 was 2.6%, and these rates are often higher in cases where chronic illnesses are present and among women, the rates are often higher (NICE, 2011). This study shall first provide a background for the patient’s case. Secondly, a plan of care would be presented. Thirdly, the delivery and evaluation of care shall follow, and finally, a summary and conclusion will end this discussion. This paper is being carried out in order to improve the management of multiple long-term conditions among patients. Background The patient Bruno (not his real name) was admitted into the emergency room after an asthma attack. Before the admission, Bruno was self-managing his asthma attacks through his regular asthma medications. He is now 70 years old. His current admission is also associated with depression. On further evaluation of his symptoms, it was determined that he was feeling very sad and lonely. I met the patient after being assigned to his care as a student nurse on my sixth week of placement. The patient’s heart rate was at 112, but he had low blood pressure at 96/50. His temperature was about 100 degrees while his respiratory rate was 22. He had poor skin turgor and this indicated that he needed immediate medical attention. This is why this patient was chosen for this paper. Based on initial laboratory tests, Bruno had the following condition: Creatinine 14.4 mg/dl, BUN 212 g/dl, bicarbonate 10 meq/l, chloride 145 meq/l, potassium 6.9 meq/l, sodium 176 meq/l, platelets 554 and hemoglobin 18.5 g/dl. Bruno’s life has been a very busy one, he worked as an economist and he was often able to easily work out math problems in his head. In his 50s, his children were all fully grown and he then participated in fund raising activities for local charities (Carrier, 2004). Bruno suddenly noted that he was losing his mathematical ability. He committed frequent mistakes and he often forgot to pay bills, turn water off, and he sometimes burned his meals (Catton, 2006). Bruno has always been mild-mannered and he seldom got angry, however, he started losing his temper especially when tired and stressed. He often held himself together long enough to get home and then lose his temper and his emotions there. This affected his relationship with his family (Titelman, 2003). He never told his doctor everything that was happening and as months went by, his mental health got the better of him and he became more difficult to live with. He finally decided to take time off work to resolve his issues and get well. After the diagnostic exams, he was diagnosed with early onset of asthma (Croghan 2006). He was also diagnosed with depression. Long-term diseases are those which also call for long-term medical attention (London Health Observatory, 2011). These long-term diseases are also diseases which often require constant care, care possibly lasting for years. These conditions include cancer, hypertension, chronic asthma, HIV/AIDS, diabetes, end-stage renal disease, and mental health issues like schizophrenia, senile dementia, and depression (London Health Observatory, 2011). Bruno’s condition are both considered long-term illnesses because he has had his asthma for almost 20 years now, and he has been depressed for months since his mother died. Based on my initial assessment of the patient, I evaluated the following essential points: his asthma would require lifetime care, and the management of his depression would also be prolonged (Keatings, et.al., 1996). He has to be within easy reach of his asthma medications, including his inhaler bronchodilator medicine, at all times. He also has to undergo therapy for his depression, and these sessions would likely last for many months, even years, depending on his progress (NICE, 2009). He also has to take anti-depressants for a certain period of time. He has to be monitored for weeks, even months in order to prevent any further suicide attempts (NICE, 2009). 2. PLANNING THE CARE What interventions were planned – what is the evidence based for this? Based on my above assessment, I was able to determine that the goal for Bruno is to control his asthma and to prevent any further attacks. For a student nurse, my involvement in the management of the patient’s asthma would involve the regular assessment of the patient’s vital signs, oxygen perfusion and saturation, breath rates, qualities in breathing, history of the disease, including asthma attacks, triggers, and possible signs which indicate an onset of an attack (NHS Choices, 2012). As a student nurse, I would review the patient’s medical history, trying to get the patient to relax and open up about his disease, including his triggers (CDC, 2011). I would also ask him what his preferred choices of medication are. In instances of actual asthma attacks, I would assist the nursing staff in managing the patient. I would make sure that the patient’s inhaler is within easy reach (Jacoby and Youngson, 2004). Inhalers are a must in any asthmatic patient’s life because these inhalers deliver a dose of drug directly into the patient’s airways and dilating such airways to ease breathing (NHS Choices, 2012). There are different types of inhalers and preferences are based on what works best for the patient. The patient does not need oral meds to manage his asthma as inhalers usually work for him. Nevertheless, for severe cases of attack, steroid tablets need to be at the ready (Hansel and Barnes, 2001). My job as a student nurse is to know where these tablets are, what conditions they should be administered, their dosage, and the adverse effects I should prepare or watch out for. I also need to know the right amount of dosage which my patient Bruno is supposed to take for his inhaler as well as his steroid tablets (if needed) (NHS Choices, 2012). His asthma and depression had significant biopsychological effects on his life. For one, his asthma limited the physical activities because on exertion and when participating in sports or social activities, he would often have asthma attacks (Batten, et.al., 2003). Psychologically, this made him feel sad and lonely. This contributed in general to his depression. His depression also limited his social activities and the more that he felt depressed (Nemade, et.al., 2007). This is a common issue among patients with chronic diseases who often feel the limitations which their disease often imposes on them and these limitations cause them to withdraw from social engagements (Nemade, et.al., 2007). A preventive inhaler was needed for Bruno, and I need to ensure that he would take it each morning and at bedtime (Jarvis, 2012). This would prevent any attacks throughout the day and the night. A reliever inhaler was also prepared for Bruno, in instances where asthma attacks occur. Since exertion and stress often triggers the patient’s attack, a reliever inhaler just before any exertion and exercise is needed (Jarvis, 2012). In order to manage the patient’s depression, he was prescribed the antidepressant Lithium. As a student nurse, I assisted in the administration of his antidepressants, checking the dosage as well time of intake; I also reviewed the possible expected side and adverse effects of the drug (Adams, et.al., 205). Upon administering the drug, I stayed with the patient to make sure he swallowed the medication and that he would have no adverse or side effects to the medication. I also reviewed the possible expected impact of the disease (Cabana, Rushton, and Rush, 2002). Antidepressants are considered the first line of treatment for moderate to severe depression, and they are also often given for short duration mild major depression among adults. These drugs often cause appetite loss, hyper-alertness, nausea, diarrhoea, headaches, and agitation (Cabana, et.al., 2002). My responsibility as a student nurse was to evaluate if and when these undesirable effects occurred, to inform the patient of these expected side effects, and to administer any other drugs which can counter these adverse effects. Psychotherapy or cognitive behavioural therapy was also indicated for Bruno. My role as a student nurse was to also provide emotional support for the patient (Schoenbaum, et.al., 2001). I brought him twice a week to his psychiatrist for his cognitive-behavioural therapy sessions and after each session brought him back to his room (Schoenbaum, et.al., 2001). As a student nurse, I also offered my emotional support for the patient, encouraging him to open up and talk about his feelings. I also encouraged him to socialize with the other patients and I offered praise whenever he showed any initiative or signs of recovery (Gilbody, et.al., 2003). These are part of therapeutic care which student nurses must make themselves part of. In eventually transitioning into the clinical practice, providing moral support for the patients is a skill which has to be mastered. As a student nurse, I also assisted in planning supportive psychotherapy for the patient. Supportive psychotherapy work best in groups. Group therapies can help patients talk and share their experiences with other people who have experienced what they have experienced as well (Ma and Teasdale, 2004). I checked the schedules for group therapies and planned what schedule my patient can be included in. These group therapies are also meant to teach patients how to cope with their loss, their feelings, and their issues (Unutzer, et.al., 2002). The patient was slotted in every Tuesdays and Saturdays with a group of patients also suffering from depression after the loss of a loved one. He was scheduled to attend 10 sessions and two hours for each session. After discharge, this group would continue to be his support group with weekly sessions he can opt to attend. The psychiatrist shall initially supervise the meetings, and the weekly sessions shall eventually be supervised in the community by a mental health expert (Ma and Teasdale, 2004). This type of session has been considered effective because it has been known to assist patients in opening up about their difficulties, their pain, and their feelings in general (Unutzer, et.al., 2002). The presence of the nurse as a mental health professional also points and guides the sessions in productive directions and he can also help the patients understand what they are going through. The sessions are also meant to establish a sufficient framework with which to ensure effective recovery from the depression (Unutzer, et.al., 2002). Were there any alternatives that were considered – what was the reason these were not considered? An alternative treatment for the patient’s asthma was the use of oral medications which serve to dilate his airways (Jarvis, 2012). Since Bruno was responding well to his inhalers, there was no need to consider the oral medications. Oral medications are considered for patients who are not responding to inhalers and for patients who prefer to use oral medications (Jarvis, 2012). In the end, not opting for oral bronchodilators is part of patient-centred care. An alternative for Bruno’s depression treatment which was considered was electroconvulsive therapy (ECT). ECT involves the use of electrodes, stimulating various parts of the brain in order to “jumpstart” the brain and often to trigger feelings of euphoria (Mayo Clinic, 2012). This is considered for severely depressed patients who are not responding to drugs or therapy (Mayo Clinic, 2012). Since the patient is responding to antidepressants and psychotherapy, there is no need to apply ECT on him. How did you involve your patient/client and/or carers? Involving Bruno and his carers in the process was difficult. Firstly, he was unresponsive during his first few days in the hospital. He was uncooperative and he refused to take any medication or submit to any medical intervention. Secondly, Bruno was sometimes aggressive when health personnel approached him. Lastly, the other health care givers did not have much patience in caring for this uncooperative patient because they also had other patients who needed urgent care. Through patience and by establishing a strong rapport with the patient, I was able to eventually gain his cooperation. Establishing rapport can work well in managing uncooperative patients (Attree, 2001). It helps establish trust and it helps the patient open up about his feelings (Yu, 2009). By establishing rapport, I was able to get the patient to trust me and he trusted my explanation on the medications he had to take and the interventions he had to agree to (Yu, 2009). Building rapport can make the job of the health professionals easier, and it sends the message to the patient that their feelings matter and that their preferences are being considered in their care (Attree, 2001). Family support was also an important element in eventually getting the patient to cooperate with his treatment regimen (Gaynor, et.al., 2003). The patient’s family visited often, and they were very eager to do what they could in order to help Bruno recover (Berkman, et.al., 2003). He was now survived by his children who were eager to see him recover. After discussing the patient’s condition with them, they were very much aware of their father’s asthma and they were also helpful in expressing how their father’s asthma was often triggered by stress. They also knew the different ways they could do in order to help their father get through each attack. They were however at a loss about their father’s depression. They understood however why he was going through it and how they needed to give him all the support they could in order to help him get through his depression. As a student nurse, I suggested ways by which they could extend their support for their father. I advised them to visit as often as they could because the greater the emotional support they could give, the better his chances are for managing his depression (Henderson, 2003). Listening to him and talking about feelings of loss would also help them get through the very cause of the depression. 3. DELIVERING AND EVALUATING THE CARE What happened when you delivered the planned care? When I established and delivered the plan of care for the patient, Bruno was resistant at first, however, as I was able to establish a good rapport and educate the patient about his disease, the patient was able to understand what he needed to do in order to recover (Yu, 2009). The plan of care was also difficult to implement because the family did not have the time to assist in the patient’s care. However, when I suggested a better schedule for the family to work with, they eventually agreed on how well the care of the patient would work. These adjustments helped me achieve better asthma management as well as better management of the patient’s depression (Yu, 2009). What worked well and why? The group therapy worked well for the patient. Bruno was opening up more to other people. He was less lonely and he was more engaging with other people. He was also more cooperative in his treatment and he had fewer suicidal thoughts (Brook, et.al., 2003). He also regained his appetite and was more sleeping regular hours and lengths of time. He also became more interested in participating in other social activities after the group sessions because he wanted to interact again with other individuals. As for his asthma, taking preventive inhaler medications before any exercise or exertion also worked well for him because he was breathing better and had fewer asthma attacks (Jarvis, 2012). Eventually, his heart rate, breath rate, and oxygen perfusion improved. What didn’t work – why didn’t it work? What might have worked better? The individual psychiatric sessions did not work well for him. He did not do well in individual sessions because he felt that he had no choice but to talk to the psychiatrist about his feelings. And in the end, he felt that his psychiatrist did not really understand what he was going through. The individual sessions were a bit too confrontational for him and it made him defensive about his actions, his choices in life, and his behaviour. He did not like these circumstances because he felt like he was being judged as a person. I believe that a community-based set-up would work best for the patient. Since the group therapy worked well for him, immersing him in a community setting would also help him open up to other people (Brook, et.al., 2003). This would make the set-up for the patient less confrontational and less threatening (Brook, et.al., 2003). Community treatments and interventions can also help reduce hospital admissions and involve the socialization process of the individual (Brook, et.al., 2003). What is the evidence for this? Different studies have indicated the great value of community treatments in the management of depression (Ciechanowski, et.al., 2004). Community treatments help reduce hospital admissions and also help provide moral and emotional support for the patient among people he feels most comfortable with (Campbell, et.al., 2000). Monitoring is also improved in the community as the members of the community and the health professionals in the community can schedule regular monitoring activities for the patients. Monitoring the asthma patient is also better in the community setting because triggers are better managed and attacks are prevented (Jarvis, 2012). Health services can also be established based on a team approach where the community mental health professionals can coordinate with each other in order to plan the patient’s care (Brook, et.al., 2003). Community treatment and group therapy is more effective than individual or single-based therapy because it is less threatening to the patient and it engages the socialization process in the patient’s care (Goldney, et.al., 2001). It is also more organized and more collaborative in approach (Brook, et.al., 2003). It is a useful tool because it is a treatment which helps prevent hospital admissions and even institutionalization of mental health patients. It also reduces stigma and discrimination of mental health patients (Von Korff and Goldberg, 2001). In the end, community and group-based therapies provides a holistic and supportive treatment for antidepressants. Community and group-based treatment is also a useful tool in managing depressed patients as well as those with asthma because the diverse needs of the patient can be given adequate attention (Brook, et.al., 2003). It also helps improve the patient’s relationship with the community, improving his socialization skills, and allowing him to interact with friends and neighbours while also participating in sports and other activities. In the end, a stronger and more effective support system can be built and established for the patient. Such a support system would also include individuals familiar to the patient in an environment also familiar to the patient (Von Korff and Goldberg, 2001). Relapse would also be reduced under these conditions and improved patient outcomes can be secured. 4. CONCLUSION My client was discharged from the mental health unit after five months of treatment. His medication compliance was improved and he was no longer depressed. His asthma attacks were also reduced and well managed. He gained weight and was sleeping regular hours. He was also eager to rejoin his family. His plan of discharge was established by coordinating with his family and with the community. Future appointments were also schedules. The mental health practitioners in the community setting were informed of the patient’s condition and schedules or supportive therapy was also scheduled. Reflection After caring for Bruno, I learned that depression can be a debilitating mental health condition because I used to believe that being depressed was synonymous with being lonely. I learned that depression is much worse and that it can lead to unfavourable patient outcomes. I also learned that asthma attacks can be traumatic for patients and exposure to more attacks can cause the patient stress and anxiety. I also learned however that there are various options open for patients and for health professionals. Different patients may opt for different forms of treatment. The key is finding what best suits a patient. Bruno prefers inhalers for his asthma and he also prefers group therapy. Any intervention plan for the patient must include their preferences in order to maximize patient outcomes, to prevent any relapse and, to ensure more cooperation from the patient during the treatment process. I also learned that establishing rapport with the patient is difficult and requires time and patience. However, as soon as it is secured, the patient can be more cooperative and can be more involved in his recovery. It is therefore important for the health professionals to take the time to establish rapport with the patient in order to achieve the best results possible. References Adams, M., Josephson, D., and Holland, L., 2005. Pharmacology for nurses: a pathophysiologic approach. London: Pearson/Prentice Hall. Asthma UK, 2012. 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