Primary Care and the Adult Nursing Patient

This essay will provide a critical account of the health requirements of a patient suffering from a chronic medical condition. It will concentrate on the experience of caring for a diabetes sufferer within the community. Due to the nature and longevity of the patient’s condition, a greater standard and longer duration of care was required. The Nursing and Midwifery Council (NMC, 2008) Code of Professional Conduct Guidance on has been maintained throughout this essay and therefore, all names have been altered for the purpose of confidentiality and anonymity. Permission to discuss the case anonymously has been given by the patient and staff involved.

The patient. Mr Thompson had been suffering from type 2 diabetes for many years. Despite the occasional minor ulcer on his right foot, for a diabetic man of 69 he had generally been in good health. However without his wife, who had passed away three years ago his adult children, whose family commitments meant they were seldom around. His ulcer quickly worsened. The pain became so unbearable that he contacted his surgery and to complain that his foot ulcer made it difficult to walk. It was confirmed that an appointment would be made for Sarah, the district nurse, to visit Mr Thompson at his home.

During her visit Sarah used a Doppler test to examine his foot. According to Bradshaw (1994) concept of need, patients experience different types of needs and it was clear from Mr Thompson’s complaints that a ‘felt need’ was present. Any possibility of a mere exaggerated expressed need was soon eliminated when upon physical examination Sarah found grounds to diagnose the matter as serious. Evidently both normative and comparative needs applied in Mr Thompson’s case-as he was experiencing a higher level of suffering than would normally be expected of a diabetic sufferer. He was therefore referred to a multidisciplinary foot care team.

In order to determine appropriate treatment according to Clinical knowledge Summaries; National Health Service (CKS) (NHS 2009) the team would asked the patient numerous questions. By reviewing Mr Thompson’s medical notes they could identify any history of foot complications and may require repeat, altered treatment methods and medical advice if no foot care advice had been given previously. Mr Thompson stated that whilst he had initially followed all advice given by medical staff he had been very negligent since becoming a widower and this had not been the first time he had required such assistance. In the immediate aftermath of his wife’s death Mr Thompson had shown similar signs of neglect and consequently a Community Matron was assigned to provide help and support.

As a Community Matron her role involved caring for the patient in secondary settings and encouraging self sufficiency. Community Matron (NHS 2009) points out that Matrons generally work as part of multi-professional and multi-agency teams with several members involved in caring for one patient. In Mr Thompson’s case the Matron took particular care to include his family in organising a better care plan to control his diabetes and tend to his foot ulcers.

She acted as ‘case manager’ a first point of call for general care, providing support and giving advice. She also performed regular examinations on the patient and managed all comprehensive medical history notes. Such extensive planning, partnerships, follow-up visits, assessing and evaluating, were essential to meet his ever-changing health and social care needs. But in such situations the job of a Community Nurse is far from easy. Their schedules can be erratic visiting patients monthly or as frequently as several times a day.

Recent government policies aim to improve the quality of patient care, reduce the number of hospital patients and deliver more health care to patients at home. But this coupled with the aging UK population and increased diabetic survivor rates means the demand for (out-patient) care is increasing. On one hand such statistics positively indicate success in medical advancements and a healthier population; however the link between old age and diabetes may also explain the increased number of sufferers. The overall effects are that hospital staff are increasingly struggling to meet demands.

Shift work may rise and even fewer Matrons will work independently on a case-by-case basis, thus resulting in a breakdown of strong patient-nurse relationships. Instead continuity of care may operate primarily through partnerships, shared nursing roles and the involvement of social services, voluntary agencies and NHS organisations such expert Patient Programmes Community Matron (NHS 2009). However with a number of cases involving staff negligence and abuse of elderly patients proper training and monitoring of staff would be crucial but may also prove time consuming and costly. (Leeds general hospital 2007)

Due to the interpersonal nature of their duty, District nurses play a crucial role in the primary care those suffering from long term illnesses. Their home visits and interaction with family members, provides emotional support by developing close trusting relationships, and quickly identify health problems. With Mr Thompson’s growing dependency on carers and unsuitable home conditions, Sarah decided it best to admit him into a residential care home.

By consulting his family and obtaining his permission before finding a suitable home she executed a good care giving strategy. The Darzi’s report Department of Health (DoH 2008) view that patients should be given a choice in care plans, and also with his legal right to privacy. It is likely that the nurse-patient bond heavily influenced the cooperative decision-making process and eased the transition from full independency to a primary like setting. At the same time District Nurses must act as teachers and counsellors, helping patients regain independence by showing patients or carers how to confidently perform care-giving duties in the absence of the nurse. Therefore play an indirect but crucial role in keeping hospital admissions and readmissions to a minimum.

The physiological effects of diabetes can be extremely burdensome and due to the likelihood of glucose damaging the nerves, they are prone to infected extremities leading to problems like diabetic foot. To prevent such issues (CKS) (NHS 2009) point out that sufferers must take particular care to keep fingernails and toenails short and clean and wear specialist shoes. Feet should be checked regularly for cuts, blisters or grazes which might otherwise go unnoticed if there is nerve damage and loss of sensation. The multidisciplinary team should be alerted should minor injuries worsen or do not start to heal within a few days.

According to (CKS) (NHS 2009) the risk of developing type 2 diabetes increases with age, possibly because as people age they become less active, gain weight- and this affects their mobility and weakening their circulatory system. However this viewpoint is fairly weak as whilst white people over the age of 40 are prone to developing the illness, ethnic minority groups are affected from age 25 years upwards. This distinction suggests that diabetes may relate to dietary choices. Another possible explanation for the development of type 2 diabetes is a genetic link, where people are more likely to develop diabetes when a close relative already has it. There is also an increased risk of developing type 2diabetes if a person has either impaired fasting glycaemia (IFG), or impaired glucose tolerance (IGT). These conditions are sometimes also known as pre-diabetes, and mean that blood glucose level is higher than usual, but not high enough to cause diabetes. IFG and IGT can both progress into type 2 diabetes if preventative measures are not taken.

Even after diagnosis (DoH 2008) suggest that measures can be taken to improve the lives of diabetics. Although diabetes cannot be instantly cured, it can be controlled using medication and other therapies. Foot problems caused by diabetes mean more patients spend more time in hospital and thus hospital resources are used on treatment or surgery, which is often very costly. But research such as that conducted by the NICE guidance recommends, (alongside a regular review of patients’ feet), care from a multi-disciplinary foot care team National Service Framework (NSF 2005). Such teams operate using a good level of interaction and communication.

They aim to identify risk factors, eliminating or prolonging the development of ulceration and can significantly reduce the incidence of complications and amputation (Armstrong et al 1998, Edmonds et al 2004). Additionally the preliminary diabetic foot assessment is the keystone to any preventative management strategy. Once possible causes of ulcers are identified measures can be taken to counter such risks. However such assessments are based solely on probabilities and the key causative factors are neuropathy, peripheral arterial disease and elevated foot pressures caused by deformity, callus and/or footwear (Edmonds et al 1999, National Institute for Clinical Excellence (NICE) 2004).

Expert Patient Programmes (DOH 2007) have also proved beneficial and involves lay members who nurse patients. Reports suggest they have been considerably successful at regaining patients’ independence. Often, particularly with older diabetics, conditions greatly limit their ability to perform mundane tasks, hindering their quality of life (DoH, 2007). However negligence, as in the case for Mr Thompson meant that he was eventually forced to revert back to the primary care of the hospital, where he underwent an extensive array of medical procedures. The surgeon drained and debride his infected feet, grafted skin over large defects, performed vascular bypasses and amputated unsalvageable limbs. Interventional radiologist x rayed Mr Thompson’s foot interpreted the X-rays and performs angiography and angioplasty.

Clearly extreme measures were also taken by staff to promote self care by ensuring he was well educated about prevention. According to Foster A, Edmonds M (2001) The Orthotist would provide suitable footwear and foot care advice, the nurse cleansed and dressed his wounds and further advised on wound care, the podiatrist performed neurological and vascular assessments and acted as the patient’s advocate. Although great measures were being taken to prevent Mr Thompson’s condition from worsening such a lengthy and traumatic ordeal could have been avoided had he been properly monitored and reviewed whilst living independently. His hospitalisation had defeated the key government objective. However with increasing medical knowledge it is becoming easier to take preventative measures, such as targeting high risk groups.

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