Essay Instructions: ASTHMA ESSAY
3500 word essay
Based on case study (not included in word count)
Written from perspective of a Nurse Practitioner reflecting on the case of patient who came into his/her care.
Essay focuses on atopy and asthma and importance of reviewing patients before increasing therapies (as explained below).
Must include UK and Global references, including latest British Thoracic Guidelines and NICE Guidelines available both online and through print sources.
INTRODUCTION
Identify background / key issues that are to be discussed i.e. stepping up asthma treatment, and importance of the review itself, i.e. checking device technique, concordance with therapy and identifying new or exacerbating triggers.
CONTENT
This is the main bulk of the essay. Discuss and expand on the issues identified in your introduction, making reference to appropriate literature and guidelines.
Discuss the fact the patient chose to access a Walk in Centre (unscheduled care) and analyse the different reasons why this setting may have been chosen by the patient, as well as overview of challenges for the practitioner working in this environment i.e. no medical records, no continuity of care, no access to test results etc. Include within this an overview of the Nurse Practitioner role.
Introduce the patient, their own medical history, drug history, allergies and social history, also their socioeconomic and cultural background and provide a reasoned analysis of why these aspects are relevant to the patients presentation (supported with research). In particular, atopy and links to asthma, focusing on the presence of pets (cat allergies specifically) and why some patients can live with a cat for years without asthma symptoms, then another cat introduced to the household can trigger an exacerbation (support with research/evidence).
Provide an overview of how the patient was assessed with asthma symptoms..., what was it from the history that prompted the practitioner to consider asthma as a potential diagnosis (atopic history (dry skin/rhinitis), new allergen to environment, poor medication control, reduced peak flow). This must be supported with analysis using guidelines, research i.e. BTS evidence etc.
Critique the management plan (which consisted of the 3 staged approach of asthma review; i.e. check concordance, check inhaler technique, check for new triggers - reference), also the use of combination therapy as method improving concordance and the importance of controlling allergy factors with asthma (evidence). Discuss and interpret the management plan including a critical analysis and evaluation of the patient, past, present and future management (i.e. discussion regarding how the patient was put on both inhalers one month ago, then this was increased, and given antibiotics....without checking concordance, technique, new triggers etc). Perhaps in hindsight a week of prednisalone would have been useful - discuss?
Provide an overview of the effect of chronic illness on the patient and their family, in the context of quality of life, exacerbations etc.
Discuss the education given to the patient and its importance, supported with evidence and relevant literature. In particular the importance of patients understanding how to use their medicine (referenced), importance of asthma management plans (referenced) and know when to seek help (referenced).
CONCLUSION
Summarise key issues, linking together main discussion points to bring your essay to a rounded conclusion.
Key points:
Importance of good asthma reviews
Importance of history taking and inhaler device assessment.
Importance of managing allergies alongside asthma management.
REFERENCES
No less than 25 references should be used. These must include extensive use of literature and research articles from Respiratory Journals and Publications, including the latest BTS and NICE guidelines.
Appendix - case study - (not included in word count)
62 year old female, presented to a Walk in centre with a 3 week history of chesty cough, chest tightness and wheezing, on top of her usual hay fever symptoms for which she was taking Multi-vitamins and cetirizine 10mg daily.
Her GP had already put her on a Becotide (2 puffs 100mg twice daily) and Salbutamol 100mcg (2 puffs as needed), with no significant improvement. After 1 week on this therapy, her GP changed it to Symbicort 2 puffs twice daily, added in Amoxicillin 250mg three times daily. At this time there were no fever/sputum/sob/anorexia/chest pain/dizziness). Judith reported a good exercise tolerance, no ankle swelling and no PND or orthopnoea. Although she denies any eczema, she did report having always suffered with dry skin particularly in skin flexures, hands etc which she uses creams for. She has also suffered with hay fever since her teens, and reports her skin flaring up occasionally with dry, cracking episodes. She takes Cetirizine from May to Sept every year.
Past medical history: ? Eczema, Hay fever.
Family medical history Mother had 'lung problems' - unsure of diagnosis. Father: unsure of illness/died very young.
Drug history: Cetirizine, Multivitamins, Symbicort.
A: No known allergies to medications. (pollen, dust = causes wheezing)
Social history: married, lives with husband of 44 yrs years, retired retail assistant, lifelong non-smoker, got a new cat 4 weeks ago (last pet died 6 months ago, a cat she had for 7 years).
On examination: Walked in, well looking, good colour, alert and orientated, speaking clearly, no acute breathlessness, oxygen saturations 97% on air, pulse 80 regular, respiratory rate 19 per minute, Peak flow measurement 270 litres per minute (predicted 400lpm) with a poor technique, eye exam normal, ENT clear, chest good air entry, slight expiratory wheeze, no crackles, percussion noted resonant, expansion equal. Heart sounds and cardiac examination normal. Skin: dry eczematous patches of skin to both dorsal aspects of hands, cracking to palms, eczema patches behind both knees, no secondary infection.
Impression: Uncontrolled Allergic Disorder +/- High probability of asthma.
Plan: long chat with patient and husband about importance of adequate control of allergy symptoms and its impact on lung health etc. Discussed importance of diagnosis, strongly advised to see practice nurse for full respiratory assessment (spirometry). Discussed medications at length, checked turbohaler technique using whistle demonstrators = very poor, full demonstration and practice undertaken, with considerable improvement in technique, whistle issued to take home with patient information. Advised use Symbicort 200/6, 2 doses twice daily, up titrated as directed, continue with cetirizine 10mg daily, add in Beconase nasal spray 2 doses each nostril twice daily, stop amoxicillin as clinically no indication at this time (patient requesting to stop due to diarrhoea), discussed allergen avoidance, long chat with patient and husband about new cat, explained it is quite possible to be unaffected by one animal and triggered by another, particularly one with long hair as her new cat has. Strongly advised to see gp for review in next week.
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