NURBN3033 Primary Health Report Sample
K1: Analyze the bio-psycho-socio-cultural concepts of living with chronic conditions/illness for Australia's individuals, groups, communities, and populations.
K2: Critically examine common chronic illnesses and the impact that these have on people across the lifespan.
K3: Discuss the role of the nurse in the provision of evidence-based care for people living with chronic illness in Australia.
K4: Identify chronic disease models and the tools and resources used to manage chronic conditions in the health care arena.
S1: Assess the factors that influence the ability of people to live with chronic illness in today's society with consideration to diverse population and minority groups.
S2: Demonstrate evidence-based and person-centred care practice to populations living with chronic illness.
S3: Apply chronic disease model/s and clinical skills principles to resolve ethical issues relevant to the care of individuals, groups, communities, and the populations with chronic illness.
S4: Consolidate and assess nursing practice standards for people with chronic illnesses.
A1: Analyse and interpret the impact of an increasing prevalence of people with chronic illness on health care, nursing practice and government policy, and discuss the strategies and interventions adopted within Australia to address this.
A2: Demonstrate the ability to apply person-centred care for people living with chronic illness who experience increased complexity and diversity of health care needs within Australia (NSQHS Standards; Aged Care Standards and Paediatric Quality Standards)
A3: Evaluate the significance of mental health literacy and consumer participation to the whole of person health in the context of their chronic illness.
Solution
Introduction
Chronic diseases refer to particular conditions that last for more than one year within the patient body and need continuous monitoring and medical attention to cure the diseases. CDM has an important role in amending the health condition of patients suffering from different types of chronic diseases and is highly beneficial in terms of reducing complications expenditure. CDM programs possess the capability of identifying and treating chronic conditions effectively and quickly and can also slow down further advancement of that disease. On this note, the successful incorporation of CCM or Wagner’s chronic care model has an important role in treating chronic patients successfully. On account of different types of benefits such as improving the patient care experiences, amending operational efficacy, enhancing the utilisation of data, increasing scalability, regulatory compliance and engagement. In the current report, a thorough assessment of the chronic care model will be done along with talking about the role of nurses in the interprofessional group. Furthermore, patient-direct SMART goals will also be developed.
Topic 1: Analysis of Chronic Care Model
Wagner’s chronic care model or CCM is considered to be a specified framework that has been established for amending the outcomes and manager of different types of chronic diseases (Gordon et al., 2020). Such a framework has been developed by Dr Wagner and his adjacent group for emphasising a patient-centred and proactive approach to treating patients suffering from different types of chronic diseases. There are different types of components present within the model which are amended patient outcomes, patient-centred care, improved care quality, cost-efficiency and efficacy, integration of resources concerning communities and supporting the healthcare providers.
Analysis of Two Components
The two fundamental and crucial components for university assignment help are self-management support and clinical information systems. Considering skill management support, it can be expressed that such a particular component helps in amending health outcomes and enhancing patient satisfaction (Goh et al., 2022). It has already been discerned that patients who are involved in making active participation during taking care of their diseases are having better control over diseases. Furthermore, it also empowers the patients to feel more satisfied while taking care of their health status. In addition to this, it also makes the overall system highly cost-efficient and consequently, this can ultimately lead towards lower expenditure in healthcare facilities and hospital admissions. This is being done by the aforementioned component through managing conditions and preventing complications efficiently.
In the case of the second component, which is clinical information systems, it has been found that this particular component of Wagner’s chronic care model is engaged in enhancing the care coordination system. As a result, augmenting the communication level among the healthcare providers can be achieved easily. Not only this but also, the clinical information component also has an influence on improving the average efficiency and accuracy level of healthcare professionals since electronic records are used (Longhini et al., 2022). This is also being done by streamlining administrative procedures. On top of all of these, drawing informed and timely decisions can also be made since the different types of support tools are implemented by healthcare professionals to obtain access to the patients’ data. This component also helps in identifying and managing high-risk patients and chronic conditions respectively even at the population level.
Benefits of using the model for Sarah
There are several potential advantages of using this model in Sarah’s case. For example, it can be stated that it will be easier for Sarah to connect with community resources like financial assistance programs, patient advocacy teams and so on to remove the burden of medical disbursements. Healthcare organisations having a clear focus on managing chronic diseases can also make certain that Sarah is getting proper treatment which can also lower fragmented care risk (Kalav, Bektas & Ünal, 2022). In addition to this, proper application of this model will also help the patient mentioned in the case study to monitor her conditions regarding her skin rash, swelling, joint pain and many more. Sarah will also be capable of getting emotional care and support from the counselling teams which will be quite beneficial for ameliorating her mental state and isolation feeling.
Topic 2: The Nurse's Role in the Interprofessional Team
Sarah is currently facing issues managing her treatment and monitoring of SLE which is not only impacting her social life but mental health. Thus, the two most important elements in a Nurse's role will be to create proper coordination between support and care along with increasing the health literacy of Sarah. Through this, Sarah can be empowered to self-manage.
Increasing the health literacy of Sarah
The nurse can work in an interprofessional team by enabling everyone to know about current conditions and progress in the treatment of Sarah. Based on the communication, shared decision-making will be ensured to make a customised plan for Sarah to enhance her literacy. In this regard, the nurse is first required to communicate with the physician who can diagnose Sarah to evaluate potential treatment options along with understanding Sarah's current knowledge gap. After proper identification of her triggers and the impacts of the medications taken by Sarah, a customised learning plan can be made by the nurse. Moreover, based on the current lifestyle and needs of the patient, specific and measurable objectives will be identified to improve her condition (Mohamed Elmetwaly, Younis Ahmed & Mohamed Mohamed, 2021). From the case study, it is observed that flare-ups are unpredictable for her. Thus, the nurse must ensure to educate her about the early symptoms of flare-ups such as a sudden increase in joint pains and fever without an infection. Moreover, she will be provided with accurate guidance to take preventive measures early to avoid such incidents suddenly. This will include nutritional guidance also recommended by a dietician to improve her overall health and capability to manage symptoms of SLE (Aim et al., 2022). A few interactive sessions will also be arranged for her by using non-technical and simple medical language to increase her awareness of the disease and proposed preventive measures. This must be a two-way conversation where Sarah will be encouraged to express her concerns and ask questions to clear her doubts. Moreover, a mental health counsellor will also be recommended to her so that she can get the necessary help to reduce her stress level and enhance her mental health (Aim et al., 2022). All these aspects will enable Sarah to self-manage SLE.
Introducing a balanced approach of support and care to Sarah
The nurse will collaborate with other healthcare professionals to create an integrated plan for Sarah. It will be ensured by the nurse that every team member is aware of the patient's condition and implements changes in her medication and treatment process. Through this, any conflicting procedures can be avoided. The approach will cater to the psychological, emotional and social needs of Sarah along with handling her physical condition (Petrocchi et al., 2022). This, a rheumatologist, mental health professional and dermatologist will be included in the team. Lab tests will be done collaboratively while evaluating her condition along with maintaining regular follow-ups. Through this, an integrated approach will be ensured. The nurse will constantly provide emotional support to the patient by actively listening to them with empathy (Appleton, 2024). Through this, her current psychological stress can be reduced before recommending her to a mental health professional. Moreover, she will be assisted with necessary medication management to ensure she understands everything efficiently. Various support groups can also be arranged for Sarah if she needs health services at home. Through this, continuous support and care will be arranged for her.
Topic 3: Patient Direct SMART Goals
1. Increasing ability of Sarah to manage her mental stress through relaxation and mindfulness techniques within 4 months. Sarah will be guided to practise relaxation techniques for at least 4 days a week. This will initially include 5 minutes of deep breathing exercise which will be later increased up to 10 minutes. The patient will be guided by the nurse about how to use this relaxation technique effectively so that she can incorporate it into her daily routine. She is currently required to manage her high-stress level as it can be a potential trigger to her flare-ups. Moreover, high mental stress can also intensify her symptoms along with her ability to cope with the disease (Thomas, 2023). Thus, this strategy will enhance her mental ability.
2. Walking has a crucial role in enhancing the physical and mental health issues as well as getting rid of different types of autoimmune flare ups (Hinman et al., 2023). Making 30 minutes walking on a daily basis will be continued for a minimum of 3 months. Amending walking time daily for around 30 to 60 minutes. Tracking the walking time utilising reliable mobile applications or feetbits. In addition to this, removing different types of complicated healthcare issues, walking can be highly serviceable for Sarah. In the very initial phase, 10 minutes of walking can be sufficient to become accustomed with the exercise (Teo et al., 2021). Gradually, the time duration has to be augmented. Doing physical activities on a regular basis can be highly fruitful for improving joint pain and swelling issues of the patient. Since walking is engaged in strengthening muscles that helps in shifting pressure from adjacent joints, due to this reason it can help to lower the pain level.
Justification for each goal
The first SMART goal to manage Sarah’s stress level is highly important to strengthen her immune system and overall health which can potentially reduce occurrences of flare-ups. Moreover, her motivation to Manage SLE can also be increased through proper mental support. By incorporating relaxation techniques in her daily routine both her physical and emotional needs can be catered to.
In the case of the second SMART goal, it can be stated that after going through the provided case study 1, it has become quite clear that the patient namely Sarah has already started suffering from joint pains and swelling. In this context, walking is considered to be one of the most fruitful exercises which can reduce joint pain (Pocovi et al., 2022). Taking this factor into consideration, such a SMART goal has been selected.
Support from Nurse to the patient in achieving these goals
The Nurse will play a significant role in educating Sarah about the relaxation techniques and their associated benefits. A guiding session can be provided to her to increase her knowledge regarding effective breathing exercises so that Sarah can perform them effectively (Thomas, 2023). Weekly follow-up can also be ensured so that her progress can be monitored.
In ensuring the successful achievement of Sarah's second SMART goal, the nurse will motivate or influence her to go for a walk based on her physical state. Furthermore, it will also be done by the nurse to monitor whether or not Sarah is fulfilling her target during walking and gradually increasing her time.
Conclusion
From the above analysis, it can be observed that the condition of Sarah is currently very critical. She is going through many physical problems such as joint pain, skin rash, swelling, fatigue and many more. However, her mental condition is also not well due to the need for constant monitoring and treatment adjustments. Thus, by considering Wagner's chronic care model it has been identified that clinical information systems and self-management support are the major components in heart treatment. Through this, necessary financial assistance can be provided to Sarah along with other treatment procedures. The role of the nurse is very significant in the interprofessional team as she can enhance the health literacy of Sara regarding the disease and other symptoms. Moreover, a nurse can ensure that everyone in the team is well aware of her condition and progress in her treatment to take effective steps. A smart plan has been created for Sarah to manage her mental stress and increase her physical activities. The nurse will also play an important role in helping us understand the correct ways to implement the goals in her daily life.
References
Aim, M. A., Queyrel, V., Tieulié, N., Chiche, L., Faraut, J., Manet, C., ... & Dany, L. (2022). Importance of temporality and context in relation to life habit restrictions among patients with systemic lupus erythematosus: A psychosocial qualitative study. Lupus, 31(12), 1423-1433. https://lupusplus.com/wp-content/uploads/2022/08/Aim-et-al-Life-habits-restrictions-SLE-Lupus-2022.pdf
Appleton, K. A. (2024). “You are not the Same Person You Were:” On Diagnosis Seeking During a Liminal Period and Systemic Lupus Erythematosus. https://digitalcommons.usf.edu/cgi/viewcontent.cgi?article=11449&context=etd
Goh, L. H., Siah, C. J. R., Tam, W. W. S., Tai, E. S., & Young, D. Y. L. (2022). Effectiveness of the chronic care model for adults with type 2 diabetes in primary care: a systematic review and meta-analysis. Systematic Reviews, 11(1), 273. Retrieved from: https://link.springer.com/content/pdf/10.1186/s13643-022-02117-w.pdf
Gordon, K., Gray, C. S., Dainty, K. N., DeLacy, J., Ware, P., & Seto, E. (2020). Exploring an innovative care model and telemonitoring for the management of patients with complex chronic needs: qualitative description study. JMIR nursing, 3(1), e15691. http://dx.doi.org/10.2196/15691
Hinman, R. S., Hall, M., Comensoli, S., & Bennell, K. L. (2023). Exercise & Sports Science Australia (ESSA) updated Position Statement on exercise and physical activity for people with hip/knee osteoarthritis. Journal of science and medicine in sport, 26(1), 37-45. Retrieved from: https://research-management.mq.edu.au/ws/portalfiles/portal/127310226/110554513_AAM.pdf
Kalav, S., Bektas, H., & Ünal, A. (2022). Effects of Chronic Care Model?based interventions on self?management, quality of life and patient satisfaction in patients with ischemic stroke: A single?blinded randomized controlled trial. Japan Journal of Nursing Science, 19(1), e12441. DOI: 10.1111/jjns.12441
Longhini, J., Canzan, F., Mezzalira, E., Saiani, L., & Ambrosi, E. (2022). Organisational models in primary health care to manage chronic conditions: A scoping review. Health & social care in the community, 30(3), e565-e588. Retrieved from: https://onlinelibrary.wiley.com/doi/pdf/10.1111/hsc.13611
Mohamed Elmetwaly, R., Younis Ahmed, A., & Mohamed Mohamed, Y. (2021). Effect of nurse-led lifestyle intervention protocol on associated symptoms and self-efficacy among patients with systematic lupus erythematosus. Egyptian Journal of Health Care, 12(1), 814-830. https://ejhc.journals.ekb.eg/article_156266_fde4e8de87d5577558ce68a51345495b.pdf
Petrocchi, V., Visintini, E., De Marchi, G., Quartuccio, L., & Palese, A. (2022). Patient experiences of systemic lupus erythematosus: findings from a systematic review, meta?summary, and meta?synthesis. Arthritis Care & Research, 74(11), 1813-1821. https://acrjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/acr.24639
Pocovi, N. C., de Campos, T. F., Christine Lin, C. W., Merom, D., Tiedemann, A., & Hancock, M. J. (2022). Walking, cycling, and swimming for nonspecific low back pain: a systematic review with meta-analysis. journal of orthopaedic & sports physical therapy, 52(2), 85-99. Retrieved from: https://www.jospt.org/doi/pdf/10.2519/jospt.2022.10612
Teo, P. L., Bennell, K. L., Lawford, B., Egerton, T., Dziedzic, K., & Hinman, R. S. (2021). Patient experiences with physiotherapy for knee osteoarthritis in Australia—a qualitative study. BMJ open, 11(3), e043689. Retrieved from: https://bmjopen.bmj.com/content/bmjopen/11/3/e043689.full.pdf
Thomas, T. (2023). Challenges and Coping Strategies of Children with Systemic Lupus Erythematosus (SLE). http://www.digitallibrary.loyolacollegekerala.edu.in:8080/jspui/bitstream/123456789/2902/1/TONY%20THOMAS.pdf
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