Chronic Obstructive Pulmonary Disease (COPD) Essay Assignment Paper
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Introduction:
This assignment discusses the anticipatory and alternative approaches for long-term conditions from different aspects. It consists of five patches explaining the importance of COPD self-management plan, response to COPD deterioration, the role of telehealth in managing those patients as well as philosophy of anticipatory care relating it to nursing models.
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Patch one – learning outcome one: self-management strategies.
Approximately three million people are believed to have chronic obstructive pulmonary disease (COPD) in England, with around 30,000 lives lost as a result each year making it the fifth biggest cause of mortality and morbidity in the UK (Stewart et al., 2011; Wilson et al., 2015). Self-management can play a vital part in the management of COPD and can also give the patient a greater sense of autonomy, thereby improving their quality of life (Robbins et al., 2013; Sallnow, Kumar, & Kellehear, 2013). Self-management plan should be comprehensive, individualized and tailored to suit each patient as they have varying symptoms and needs that require individualized plan in order to achieve optimum health outcome. For that reason, there should be a great cooperation, education and person-centered support from specialized health professionals who are COPD knowledgeable and properly trained (Cornforth,2013  ). Based on that, clinician’s goal should be directed towards working with COPD patients collaboratively to discuss and negotiate their tolerated healthy behaviors, the disease nature, its management and encouragement of possible life style modifications, for instance, more exercise, healthy eating, correct inhaler technique and basically smoking cessation (Cornforth,2013).
Patients who have early-stage COPD may not display their symptoms in a way that they recognise (Robbins et al., 2013; Sallnow, Kumar, & Kellehear, 2013); but as COPD worsens there is an increase seen in wheezing, coughing, sputum production, and dyspnoea (Sharp, Moran, & Kuhn, 2013). In some patients these symptoms may become so severe that long-term oxygen therapy is needed (Sharp, Moran, & Kuhn, 2013). It is important that patients are able to recognise their own symptoms and thus any changes in them, which can be done by keeping a daily record (Stewart et al., 2011).
It is important that patients take their medications as prescribed, even during periods of feeling well (Robbins et al., 2013). Continuous use of medication can help prevent exacerbations; but it is important to check for any interactions that may occur with medicines which are available without prescription (Sallnow, Kumar, & Kellehear, 2013). In addition to regular medications, it is also important that patients receive annual vaccinations such as the flu jab and an anti-pneumococcal vaccination which protects against serious infections caused by pneumococcal bacteria (Sallnow, Kumar, & Kellehear, 2013).
Self-monitoring in COPD is a key tool in preventing exacerbations (Sharp, Moran, & Kuhn, 2013). Evidence suggests that there is an increase in COPD symptoms about 24 hours before the onset of a full exacerbation (Robbins et al., 2013; Sallnow, Kumar, & Kellehear, 2013). If antibiotics and/or steroids are started promptly this could prevent a hospital admission (Sallnow, Kumar, & Kellehear, 2013). Although there is some debate about which parameters patients should measure, there are a number of parameters which are usually monitored, including symptom score, peak flow/FEV1, and pulse oximetry (Sallnow, Kumar, & Kellehear, 2013). Chronic Obstructive Pulmonary Disease (COPD) Essay Assignment Paper.
The most important lifestyle modification a patient with COPD can make is to stop smoking, or reduce the amount they smoke if they cannot stop completely (Robbins et al., 2013). Stopping or reducing smoking can reduce symptoms of COPD, reduce the rate of decline in lung function, and improve quality of life (Robbins et al., 2013; Sallnow, Kumar, & Kellehear, 2013). Patients may also benefit from a pulmonary rehabilitation programme which is usually delivered by a team of specialists and may include breathing exercises, a nutritional programme, and give educational advice about the disease and strategies to manage it (Robbins et al., 2013).
Patch two – learning outcome two:  care providers response to a deterioration in COPD patients.
Patients with COPD who have deteriorated or are reaching the end of their life often have an increase in symptoms, particularly coughing, dyspnoea, and anxiety and/or depression (Townsend, 2014). In order to provide effective care for these patients the interventions and responses should be aimed at easing symptoms such as breathlessness and pain and psychological symptoms such as anxiety and depression (Townsend, 2014). Palliative care should be thought of as a series of actions, interventions, and responses to treat the whole patient, including psychological factors, not just physical manifestations of the disease (Badger et al., 2012;Liaw, 2016). The goal of palliative care should be to prevent and relieve suffering and to reach the best possible quality of life for the patient (Badger et al., 2012; Liaw, 2016). In order to be able to meet this goal, care will be provided by a multidisciplinary team including, but not limited to, doctors, nurses, physiotherapists, and nutritionists (Elliott, 2011; Baker et al., 2012).
Bronchodilators are often used to relieve bronchospasm and non-invasive ventilation (NIV) can be particularly helpful to alleviate signs and symptoms of respiratory distress (Elliott, 2011; Baker et al., 2012). Multi-centre randomised control trials have shown NIV to reduce dyspnoea and respiratory rate faster than the control group, and these patients also required less morphine (Badger et al.,2012; Liaw, 2016). Mechanical ventilation can also be used; but the failure to wean patients from mechanical ventilation before death occurs is well documented and the primary goal of easing respiratory distress should be to avoid endotracheal intubation where possible without causing unnecessary discomfort (Badger et al.,2012; Liaw, 2016). The decision to begin mechanical ventilation should be made in conjunction with the patient, and it is also clear that one of the key parts of patient education should be about disease progression and what treatment options are available and may be considered at each stage in order to facilitate advanced care planning (Townsend, 2014). Chronic Obstructive Pulmonary Disease (COPD) Essay Assignment Paper.
Patients with end-stage COPD often also require significant pain management. Opioids are the only class of drugs which have a proven effect on dyspnoea by inhibiting the respiratory drive (Baker et al., 2012;  Diaz-Lobato, Smyth, & Curtis, 2015). The Global Initiative for Chronic Lung Disease (GOLD) guidelines state that opioids are contraindicated in the management of COPD because of the potential for inhibition of the respiratory drive and thereby increasing hypercapnia; however the American Thoracic Society clinical policy statement on palliative care states that the use of opioids to relieve suffering is adequate justification for their use (Lanken et al., 2008). The dose of opioid should be titrated for each patient and reviewed regularly for its effect on relieving dyspnoea (Lanken et al., 2008; Diaz-Lobato, Smyth, & Curtis, 2015). Patients with end-stage COPD often also develop congestive heart failure and the use of diuretics can be particularly helpful in removing excess fluid which in turn reduces breathlessness (Diaz-Lobato, Smyth, & Curtis, 2015).
Patch three – learning outcome three: The role of telehealth in supporting COPD patients.
Digital Health is an emerging industry arising from the intersection of healthcare services, information technology and mobile technology (Monitor Deloitte, 2015), providing patients and their families with remote access to accurate information in order to make effective choices about their care (National Information Board, 2014).  Consequently, digital health services have the power to improve health, give patients more control over their health and wellbeing, empower carers, and reduce the administrative burden for care professionals (National Information Board, 2014).  Current provision of digital health services in the U.K. can be categorised as tele-healthcare (including both remote care and support using ICT and the exchange of clinical data between patient and clinician), mobile-health (mhealth) apps related to health and well-being, and patient centric educational/assisted decision making websites.
Telehealth has been used to deliver multi-faceted support to patients with COPD, including web-based self-management and exercise programs, automated feedback on patients’ daily exercise levels, and tele-consultation via a web portal (Tabak et al., 2014).  Additional benefits of tele-health to patients with COPD include early recognition of worsening symptoms through real-time monitoring, quick feedback, and access to information and support (Nguyen et al., 2013). However, a case manager is required to interpret monitoring data or determine patient feedback and this could slow the care process (Tabak et al., 2014).
The proportion of mobile phone users who use their phones to look up health information increased significantly from 17% in 2010 to 31% in 2012 (Monitor Deloitte, 2015), however only 7% of consumers aged 55-64 reported using mHealth apps (Monitor Deloitte, 2015).  A survey of mhealth engagement reported that 10% of UK responders had downloaded an app to track their health, 17% had used an app to monitor and manage fitness and health improvement goals, 15% had used an app to manage health issues, 8% had used mobile technology to receive medically related alerts or reminders, and 5% had used mobile technology to send or receive a picture related to a health problem.  For patients with COPD, apps can be utilised to report respiratory measures (including peak expiratory flow) that are flagged as at-risk by an algorithm should they deviate over a threshold from a baseline measure.  Such measures can be reviewed by health care practitioners and same day treatment provided (Cordova et al., 2016). Chronic Obstructive Pulmonary Disease (COPD) Essay Assignment Paper.
Internet based resources can play an important role in supporting patients, and their carers, living with a chronic condition.  Patients utilise the internet to conduct searches for condition related information, register to receive updates about their condition, and read/share experiences with other people with the same condition via blogs (Mahler et al., 2015).  Additionally, patients can access tailored information within online patient education programs (Farmer et al., 2014; Hewitt et al., 2015) and any online support groups (Kuijpers et al., 2013).  Jones et al (2014) reported that 85% of patients with a chronic condition had either direct or indirect (family member or carer) access to the internet.  In the U.K., patients have access to a number of large national health websites that are delivered using a mass media format and generalizable across a diverse population despite evidence that more effective e-communications are tailored to specific patient populations (Jones et al, 2014).
Patch four – learning outcome four (a and b): philosophy of anticipatory care in relation to nursing models.
With an increasing elderly population and an increase in the number of people living with long-term health conditions such as COPD, there must be a change in the models of care which are used to support these patients (Sharp, Moran, & Kuhn, 2013). To this extent, anticipatory care planning seeks to establish shared decision making through a collaborative process to support a self-management approach to personal health.  This process should encourage individuals with long term chronic conditions to be aware of potential changes in their health status and to prioritise their desired future healthcare, including planning of dignity and care in practice (Steel,2015; Stewart et al., 2011; Sharp, Moran, & Kuhn, 2013).  This process should allow effective communication of personal choice, practical need and sharing of key information to those who provide care (Steel, 2015; Stewart et al., 2011; Sharp, Moran, & Kuhn, 2013).
Anticipatory care is essentially patient-centered, patient-focused, and patient-led (Steel, 2015) as demonstrated in Patch 1 through exploration of self-management strategies, symptom recognition, self-monitoring, and lifestyle modifications.  This discussion showed that self-management can play a vital part in the management of COPD, including prevention or reducing exacerbations (Paradis et al., 2011; Wilson et al., 2015), and can also give the patient a greater sense of autonomy, thereby improving their quality of life (Paradis et al., 2011; Wilson et al., 2015). Chronic Obstructive Pulmonary Disease (COPD) Essay Assignment Paper.
Anticipatory care planning was also evident within Patch 2 that discussed the actions, interventions, and responses that should be made when patients with COPD have a deterioration in their illness or reach end of life care. This discussion explored the use of non-invasive ventilation, mechanical ventilation, and medications such as opioids. This discussion is important because anticipatory care will allow patients to consider and discuss options about their care in advance of any deterioration (Badger et al.,2012; Liaw, 2016). The discussion also highlighted the need for thorough holistic assessment of patients, as palliative care should be thought of as a series of actions, interventions, and responses to treat the whole patient, including psychological factors, not just physical manifestations of the disease (Badger et al.,2012; Liaw, 2016). The goal of palliative care should be to prevent and relieve suffering and to reach the best possible quality of life for the patient (Badger et al.,2012; Liaw, 2016).
The role and extent of digital health, including tele-healthcare, mobile apps, and internet resources for individuals with chronic conditions is key to both self-management and timely care intervention in the event of a deterioration in patient health.  This was discussed in Patch 3 and is fundamental to the patient-led philosophy of anticipatory care.  The utilisation of digital resources can allow patients with chronic conditions to remain autonomous within their own home, and yet receive time appropriate treatment through real-time monitoring by remote heath care practitioners. Chronic Obstructive Pulmonary Disease (COPD) Essay Assignment Paper.
Anticipatory care is fundamentally located within a humanistic philosophy that acknowledges the needs of the ‘whole person’.  This underlying principle has given rise to several models of nursing that identify the individual as a biopsychosocial being within an ever changing environment.  A nursing model has been defined as set of concepts which are formulated efficiently , inter-related in a logical manner and based on science that describe the main elements of nursing practice along with the theoretical basis behind those concepts as well as the required values for their practice by the health care provider (McCrae et al., 2012).  An example of such a model is Roy’s Adaptation model that challenges nursing to support both the individual’s biological needs and self-perception as they adapt to a changing environment.  Similarly, Rogers theory encouraged nursing to deal with patients as a whole unit in both care design and provision.  Therefore, it could be argued that nursing differentiates itself from a medical model by seeing a person’s health as more than their biological status or presence of disease.  Consequently, the nursing process needs to be multi-dimensional in order to address the biological, psychological, sexual, and spiritual needs of patients.  Roper, Logan & Tierney’s model of nursing is widely used in the U.K. and promotes maximum independence through complete assessment of activities of living that further support independence.  Such a framework supports nurses to fulfill their duties bestowed upon them by the Nursing and Midwifery Council (2015) that registered nurses are expected to be able to make holistic and systematic assessments of their patients, which includes physical, emotional, psychological, and other needs. Chronic Obstructive Pulmonary Disease (COPD) Essay Assignment Paper.
Roper’s holistic model of nursing sought to assess the biological, psychological, sociocultural, environmental, and politic economic aspects of care and how they influenced an individual’s independence.  In Patch 1, the psychological element of Roper’s model is demonstrated by increasing patient independence through self-management strategies.  Patch 2 referred to healthcare interventions required as a result of deterioration in health and can be referenced to the biological assessment noted in Roper’s model.  Patch 3 identified the role of digital health services to support patients and families and is closely associated with both biological and psychological elements of Roper’s model of nursing.  It could be argued that a lack of literacy, including IT skills, may inhibit patients from accessing the full benefits of digital health services, and additional interventions (or adaptations) to address independence may need to be considered. Chronic Obstructive Pulmonary Disease (COPD) Essay Assignment Paper.