The following analysis aims to shed light upon the case of 59-year-old Henry, a male patient suffering from various chronic health issues like asthma, diagnosed when he had 25 years of age, and Chronic Obstructive Pulmonary Disease (COPD), diagnosed in his late forties. He even has a history of bowel obstruction, type 2 diabetes and Gout. He had to be admitted to the hospital recently due to a severe respiratory infection, and Hopsital in the Home was arranged for him after discharge from the hospital. The recent hospitalisation has led to fatigue, shortness of breath and weight loss in Henry. The analysis will also discuss two SMART (Specific, Measurable, Achievable, Relevant, and Time-Bound) goals suitable for Henry and his chronic condition.
Defining these parameters through SMART goals helps ensure that the objectives are attainable within a specific time frame. This approach eliminates generalities and guesswork, sets a clear timeline, and makes tracking progress and identifying missed milestones easier (Swann et al., 2023). The first goal would be to improve Henry’s respiratory function and management. This would involve strategies aiming at the enhancement of his respiratory function and effective management of his asthma and COPD (Yang et al., 2022). The second goal would be the promotion of balanced levels of nutrition and healthy weight gain. This would involve Henry achieving a healthy BMI. Also, with the help of a balanced and nutritious diet, it would help him to lead a healthier lifestyle (Campbell, 2017). Lastly, the analysis will also explore the role of health professionals and patient-guided interventions.
The self-management framework is a technique that is patient-centred. In other words, it focuses on the empowerment and active participation of people suffering from chronic health conditions with respect to the management of their own health and well-being. It prioritises patients receiving appropriate skills, knowledge and support and enables them to make informed decisions and engage in self-care practices (Heggdal et al., 2021). Firstly, the framework emphasises patient empowerment which sits well with the independent nature of Henry. Encouraging his involvement in the processes related to decision-making, which include treatment plans, modifications in lifestyle and goal setting, can be helpful in fostering an emotion of motivation and ownership in him (Vainauskienė & Vaitkienė, 2021).
The second element is goal setting and action plans. This can be done by setting SMART goals for Henry, enabling him to keep a check on his progress and making him feel accomplished, This will motivate him to stay focused on his health outcomes. Third is patient education which plays a crucial role in the effectiveness of self-management. Henry should be provided with an education related to his chronic conditions in a comprehensive and tailored fashion. This should also include informing him about the recognition of symptoms and identification of triggers, along with the management of and modifications to lifestyle (Kessler & Liddy, 2017).
The fourth aspect is the support network and social context, which in Henry’s case, is his children. They should also be involved in Henry’s care plan and should be equally educated regarding Henry’s conditions, in addition to lifestyle management. Furthermore, exploring community resources and support groups can also prove to be valuable (Fletcher et al., 2019). The final component involves the management of symptoms, along with regular feedback and monitoring. The self-management framework focuses on enabling individuals to promptly recognise and report symptoms, facilitating timely intervention by healthcare professionals. Monitoring Henry's health status, including lung function, glycemic control and weight, will play an essential role in progress evaluation and making adjustments necessary to his care plan (Dineen-Griffin et al., 2019).
The engagement of various healthcare professionals working as a team focusing on the complex needs of the patient and improved health outcomes is known as interprofessional care. (Hardin et al., 2017). The two other healthcare professionals who can contribute appropriately in Henry’s case are- The first healthcare professional would be a respiratory therapist. He or she would be an individual with a speciality in respiratory care and can play an essential part in the management of Henry’s asthma and COPD. He or she can assist other physicians and nurses involved in Henry’s care concerning assessing his lung function (Cousins et al., 2020). The therapist can also suggest specialised exercises related to breathing and ways to optimise the results of those exercises. Furthermore, he or she can also play a vital role in educating Henry about proper techniques and strategies associated with self-management during exacerbations.
Lastly, the therapist can also help in monitoring Henry’s response to therapies. He or she can suggest modifications or adjustments as per requirements for improvement in respiratory function (Dabscheck et al., 2022). The second appropriate healthcare professional who can prove to be an invaluable asset is a certified diabetes educator (CDE) due to Henry's history of type 2 diabetes. A CDE is a professional who has a specialisation in the management of diabetes. This can turn out to be advantageous as he or she can collaborate with the treatment team and help them in making a management plan for Henry. The educator will also be responsible for educating Henry about the administration of insulin and the monitoring of blood glucose levels. This will also help him to achieve glycemic control through a balanced diet. In additon to this, he or she can also educate Henry on how his diabetes is related to other co-morbidities like COPD (Sim et al., 2020).
The first attribute is effective communication skills, as the RN serves as the point of contact and coordinator of care for the patient. He or she plays a significant role in making sure that the information conveyed is accurate and can be comprehended by all members of the team (Godsey et al., 2020). The first component of this attribute involves active listening, which comprises paying attention to others’ opinions. It also involves comprehending their messages with empathy. This enables the RN to gather insights and information that are essential and relevant to comprehensive care through the perspectives of other healthcare professionals (Handberg & Voss, 2018).
The second component is clarity and conciseness, which expects the RN to communicate information in a manner that is clear and succinct. This involves providing findings of assessment and patient-related data that are relevant and accurate. In addition, it should also be easily understood by other team members. This can be achieved by limiting the use of jargon or other technical terminology. In addition to this, creating an environment that promotes active participation and healthy discussions related to decision-making processes is also helpful (Shahid & Thomas, 2018). The third component is assertiveness and advocacy, which demands that the RN should always be in favour of the best interest of the patient and express perspectives assertively whenever needed. Assertiveness can help in the facilitation of open dialogue and ensure that the patient's needs remain at the forefront of decision-making (Paterson et al., 2023). The last and final aspect is written communication which plays an equally important role along with verbal communication when it comes to sharing patient information and care plans among team members. Moreover, it is also essential that the documentation done by the RN is accurate, easily accessible and organised to prevent any miscommunication or obstacle in patient care (Khalil & Lee, 2018).
Adaptability and flexibility is the second important attribute. It is essential for an RN to be adaptable and flexible to ensure smooth sailing through the complexities of interprofessional collaboration (Paterson et al., 2020). The first vital component of this attribute is being open to new ideas, according to which an RN is expected to be responsive and receptive to new ideas. This includes learning and incorporating ideas into the care plan of the patient through evidence-based practices. This will encourage using the latest and most effective treatment options available for the patient (Pather et al., 2020). The second aspect is collaborative problem-solving. An RN who is adaptable and flexible in nature will be able to collaborate openly with other members of the team to a greater extent. This leads to innovative solutions and constructive sessions (Pype et al., 2018).
The third component of this attribute is being responsive to changes in the condition of the patient. It becomes possible for an RN exhibiting adaptability to be prompt in assessing any deviations or variations in the condition of the patient. This is followed by communicating it further to the team and ensuring appropriate modifications in the care plan. This promptness and presence of mind can be helpful when promoting the safety of the patient and generating optimal results (Rihari-Thomas et al., 2017). The final aspect is the quality of relationship building which plays a vital part in interprofessional collaboration and leads to the establishment of mutual respect among individuals working in a team. It becomes the responsibility of the RN to foster positive working relationships with colleagues from different disciplines and give importance to each contributing individual (Kunhunny & Salmon, 2017).
SMART GOAL 1: Improvement of Respiratory Function and Management |
SMART GOAL 2: Promoting Healthy Weight and Balance in Nutrition |
Patient-guided intervention 1: Practicing breathing exercises regularly Justification: Diaphragmatic breathing and pursed-lip breathing can be helpful with Henry’s asthma and COPD. (Yang et al., 2022). |
Patient-guided intervention 1 – Certified Diabetes Educator (CDE): Regular monitoring of blood glucose levels. Justification: The guidance of a CDE will enable Henry to interpret blood glucose readings. (Despins & Wakefield, 2020). |
Patient-guided intervention 2 – Respiratory Therapist: Participation in a pulmonary rehabilitation program Justification: Joining a pulmonary rehabilitation program under a respiratory therapist's supervision will help Henry manage his COPD. |
Patient-guided intervention 2: Following a balanced meal plan Justification: It would be possible for Henry to ensure better weight management and glycemic control (Campbell, 2017). |
Patient-guided intervention 3: Avoiding exposure to respiratory irritants. Justification: Henry’s asthma and COPD necessitate avoiding exposure to any irritants (Quirce & Sastre, 2019) |
Patient-guided intervention 3: Engaging in physical activity regularly. Justification: Daily physical activity has been found to improve sensitivity to insulin. (Khalafi et al., 2022). |
In conclusion, the self-management framework can really make a difference in the condition of Henry. His participation in decision-making and participation in the SMART goal will help him to be more active and involved in his self-care. In addition to this, collaboration with a CDE and a respiratory therapist will lead to a healthier lifestyle. The CDE would provide education and guidance related to the management of blood glucose levels and diabetes. In addition to this. They would also guide him regarding necessary adjustments in the diet along with monitoring glucose and the administration of insulin. On the other hand, the respiratory therapist would assist Henry in the optimisation of his lung function and would educate him about various strategies which can be beneficial to him with respect to the management of his respiratory condition. In addition to this, he would also guide Henry about the proper usage of any respiratory devices or equipment, along with other exercises that would help in the recovery.
Following a multidisciplinary approach like this would result in the development of a more comprehensive care plan which would address Henry’s respiratory issues and his diabetes in a parallel fashion. This will also result in improved management of his chronic conditions and associated co-morbidities, leading to a positive impact on his overall well-being. Lastly, an RN who is adaptable, flexible and suitable in communication can help in coordinating with other healthcare professionals. They can even integrative holistic care to Henry for an improved quality of life. Lastly, the holistic approach followed by an RN would involve Henry’s physical as well as emotional well-being. This would involve taking into account the various aspects of Henry’s life and tailoring the care plan in alignment. This can lead to appropriate adjustments in lifestyle and can help Henry cope with potential challenges developing a sense of trust, confidence and comfort.
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