HNN319 Chapter Notes - Chapter All expected readings : Primary Healthcare, Chronic Condition, Chronic Care
9 Jun 2018
School
Department
Course
Professor
Chronic illness readings
Week one: Factors implementing chronic care models (CCMs).
- Chronic care model; Macoll Institute 1990s. Mobilising community resources, promoting
high uality ae, ealig patiet self‐aageet, ipleetig ae osistet ith
evidence and patient preferences, effectively using patient/population data, cultural
competence, care coordination, and health promotion.
- Success depend on primary healthcare, team, organisation and contextual factors.
- Theories of implementation of complex healthcare interventions include process theory,
stage of change theory and impact theory.
- Theories for people within the intervention include cognitive, educational and motivational.
- Theories for social interactions include communication, social learning, social networking,
team effectiveness, professional development and leadership theories.
- Theories at organisational level include quality management and integrated care- basis of
implementation and development Care Models.
- Integrated Care: coherent set of methods and models on the funding, administrative,
organisational, service delivery and clinical levels. Promotes connectivity between
healthcare systems.
- Quality management based on prevention patient harm, improve services available to
healthcare providers.
- Primary healthcare: first-contact, accessible, continued, comprehensive and coordinated
healthcare provided by a single practitioner or a multidisciplinary team of professionals in a
community practice.
- First contact: accessible at time of need. Ongoing care: long term care throughout duration
of chronic illness. Comprehensive care: range of services accessible to patient. Coordination
care: role of primary care that coordinates multidisciplinary team to treat chronic illness.
- Chronic illnesses Diabetes 2, depression, COPD, chronic kidney disease, CVD: according to
WHO.
- Benefits CCM providers:
- Positie ipat patiets health, helpful fo ok, ok satisfatio, aess to futhe
resources.
- Benefits CCM patients:
- Empowerment, understanding of actions impacting health, promotes self-management.
- Disadvantages CCM patients:
- Slow results, missing online responses.
- Disadvantages CCM healthcare:
- Time to learn new CCM, confusion, lack of information, lack knowledgeable staff.
- Factors for acceptance; healthcare:
- Helpful, koledgeale staff ith eleat skills, CCMs usefuless ad eleae, suppoted
during implementation, opportunities concern and questions, clear explanation with
examples and intended health outcomes identified including clearly defined benefits of
CCM, incentives for healthcare providers, collaboration,
- Factors for acceptance; patients:
- Support groups, understandable information, encouragement, individualised to patient,
accessible resources.
- Barriers of implementing CCM; healthcare:
- Lack of nurses, management and admin support staff, high turnover staff, irregular Dr and
nurse ratio in remote locations, experience working in interdisciplinary team not
find more resources at oneclass.com
find more resources at oneclass.com
multidisciplinary team, extra work for DRs or nurses, time taken to implement CCM,
inappropriately designed resources, funding, lack of useful data, poor collection existing
measures.
- Barriers implementation CCM; patients:
- Cultural needs, varying questions, too much information, patient concerns and anxieties,
problems with adherence, low SES, lack of [accessible] resources (ie online help for elderly),
lack of personalised education/resources, lack of info specific to community, inappropriate
resources.
Practical issues in acute heart failure management:
- Acute heart failure: the rapid onset of symptoms or a change in existing symptoms;
breathlessness on exertion, oedema, pulmonary congestion (feels full of water) fatigue and
orthopnoea all resulting in limitations to physical activities and reduced quality of life.
- Decreased cardiac output: peripheries cool, confusion, low urine output, hypotension.
- Patient symptom evaluation based on past experiences.
- Presenting history: identify causes of aggravation or alleviation.
- Past history: hypertension, coronary heart disease, arrhythmias (include AF, severe
bradyarrhythmia), valve disease, medications, alcohol abuse, renal dysfunction, anaemia,
exacerbation asthma or COPD.
- Clinical history: identify potential factors heart failure ie infections, self-care advice, over
counter medications, ignoring Dr advice.
- Diagnosis tests: namely ECG, xray, RR, HR, BP, O2 stats.
- Troponin tests identify myocardial infarction. Urea, electrolytes and full blood count identify
potential cause of symptoms, such as anaemia or renal failure, and inform management
decisions. Cardiac catheter identifies heart function.
- Aim to stabilise haemodynamic condition and reduce symptoms.
- Begin management plan quickly and re-evaluate patient for deterioration.
- Key pharmacological agents include O2, vasodilators and diuretics however nurse needs to
monitor for adverse effects.
Intervention
Reason
Observations
Oxygen (only if hypoxaemic
O2 satuatio 90%
Oxygen saturation to achieve:
90% 90% i the pesee of
chronic obstructive
pulmonary disease)
Morphine/diamorphine (in
combination with an anti-
emetic)
Anxiety, work of breathing,
chest pain.
Hypotension, bradycardia,
decreased RR.
Diuretic (usually given
intravenously if there is
clinical evidence of fluid
retention)
Monitor breathlessness, RR
and O2 stats, monitor for
adverse effects of
hypovolaemia, monitor fluid
balance, evaluate response
to treatment within 30–60
minutes of IV admin. Report
response to treatment so
diuretic dose can be reduced
as soon as possible.
Refer to physician prior to
further diuretic
administration if systolic
lood pessue 90 mmHg,
monitor electrolytes for
hypokalaemia,
hypernatraemia or worsening
renal function.
find more resources at oneclass.com
find more resources at oneclass.com
Vasodilators
Monitor for reduction in
breathlessness
Monitor systolic blood
pressure (ideal >90),
headache.
Week two: Fluid management strategies in heart failure.
- Fluid retention (hypovolemia) often leads to decompensated heart failure.
- Heart failure: clinical syndrome of decreased exercise tolerance and fluid retention due to
structural heart disease. Decompensated heart failure is progressive symptoms from
previously diagnosed heart failure, requiring medical attention.
- Respiratory distress, crackles, interstitial/alveolar oedema, elevated jugular venous pressure
or jugular venous distension, findings on chest radiographs, and an S3 heart sound- heart
failure and fluid retention.
- Hemodynamic congestion, defined as an increase in left ventricular filling and/or
intravascular pressures; form of fluid retention that can still be present despite symptoms
relieved leading to worsened prognosis and progression heart failure.
- Fluid status assessments and haemodynamic care vital.
- Patients with heart failure will experience either increased or decreased cardiac output>
systematic venous pressure (after load) increases and venous circulation increases to
compensate> increased after load and impaired systolic performance increases left
ventricular end-diastolic pressure> increases pressure in alveoli>absorption capabilities
overwhelmed> pulmonary congestion.
- Heart failure> activation baroreceptors> stimulates SNS> increases afterload AND causes
renal water retention, increases peripheral atrial resistance, increases renal vascular
resistance and causes renal sodium retention> decreases sodium/H20 excretion> oedema
and fluid retention symptoms.
- Assessments:
- Improves clinical outcomes and quality of life.
- Assess for orthopnea, peripheral oedema, weight gain, need to increase baseline diuretic
dose, and jugular venous distension.
- Clinical history, past history, presentations, patient observations, vital signs, ultra sound for
left ventricular problems, cardiac and respiratory assessments.
- Fluid management strategies:
- Medication to prevent left ventricular end-diastolic pressure ie beta blockers, angiontension
II inhibitors, ACE inhibitors.
- Loop diuretics for sodium retention.
Hospital disharge patiets heart failure:
- Educating patients before discharge promotes self-care, reduces readmissions, and helps
patients spot problems early.
- Patients should be active partners in the management of their health.
- Patients should learn about their conditions and medications and when to seek medical
treatment.
- Nurses need to understand the barriers to self-care and help patients overcome these
barriers.
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Week one: factors implementing chronic care models (ccms). Mobilising community resources, promoting high (cid:395)uality (cid:272)a(cid:396)e, e(cid:374)a(cid:271)li(cid:374)g patie(cid:374)t self (cid:373)a(cid:374)age(cid:373)e(cid:374)t, i(cid:373)ple(cid:373)e(cid:374)ti(cid:374)g (cid:272)a(cid:396)e (cid:272)o(cid:374)siste(cid:374)t (cid:449)ith evidence and patient preferences, effectively using patient/population data, cultural competence, care coordination, and health promotion. Success depend on primary healthcare, team, organisation and contextual factors. Theories of implementation of complex healthcare interventions include process theory, stage of change theory and impact theory. Theories for people within the intervention include cognitive, educational and motivational. Theories for social interactions include communication, social learning, social networking, team effectiveness, professional development and leadership theories. Theories at organisational level include quality management and integrated care- basis of implementation and development care models. Integrated care: coherent set of methods and models on the funding, administrative, organisational, service delivery and clinical levels. Quality management based on prevention patient harm, improve services available to healthcare providers.
