General principals of management: education

Asthma education is an essential part of the treatment of this disease. Health care professionals must establish a partnership with the patient with asthma and the patient's family to devise a plan of care with which the patient voluntarily will comply. The partnership with the patient begins at the first encounter and continues throughout the therapeutic relationship. Each member of the health care team can be instrumental in reinforcing the crucial information the patient must know to be an informed participant in his or her care. Nursing professionals are in a particularly advantageous position to foster this partnership because of their patient-focused outlook and the quality of time spent with patients. When the partnership is based on mutual trust and cooperation, the clinician can direct asthma care that is consistent with current expert guidelines. Educational interventions should be meaningful to the patient, learner centered to incorporate the patient's needs, and sensitive to the patient's cultural influences. The patient and his or her significant social and family support should be actively involved. The clinician should be alert to the patient's readiness to learn and tailor the message to suit the setting in which it is delivered. The patient should receive information that allows his or her participation in goal setting for treatment. Essentials to be included are the significance of the diagnosis, basics about inflammation as the primary cause of symptoms, the difference between controllers and relievers, how to use the medications and monitoring devices, how to reach the provider, and the need for continuous ongoing interaction with the clinician. Goals set in the partnership are objectified in the asthma action plan or guided self-management plan. The success of the treatment can be assessed from the patient's improved asthma control and reduced reliance on emergency treatment. Every health care provider is a potential wealth of patient education. Every patient encounter is an opportunity to reinforce knowledge and proficiency in asthma management. Nursing professionals can play a fundamental and crucial role in asthma education by maintaining the focus of the medical treatment on the priorities in asthma care--the learning needs and goals of the patient.     

Update on Diagnosis and Management of Severe Asthma

Patients with severe asthma comprise 5% to 10% of the patient population with asthma, but they use 60% of treatment costs. As a result of high morbidity and mortality rates and frequent health care use, these patients are commonly encountered in primary care settings. Treatment is complex and often requires an interdisciplinary approach to reduce risks, treat comorbidities, optimize medications, and to engage patients in care. Through early diagnosis, patient education, the provision of standard of care asthma management, and close collaboration with specialists, nurse practitioners can facilitate timely and comprehensive treatment that can improve patient outcomes.     

Impact of asthma education received from health care providers on parental illness representation in childhood asthma

The burden of asthma has increased dramatically despite increased understanding of asthma and new medication regimens. Data reported here are part of a larger study investigating factors that influence parental asthma illness representation and the impact of this representation on treatment outcomes, including the parent/health care provider relationship. We investigated the influence of asthma related education provided by health care providers on these outcomes. After interviewing 228 parents of children with asthma, we found that asthma education received from the child's health care providers positively influenced parental belief systems, especially attitudes towards anti-inflammatory medications and facts about asthma. Parents who reported receiving more education also reported stronger partnerships with their child's health care provider.     

Diagnosis and periodic assessment of asthma

This chapter reviews the features of the clinical history that indicate a diagnosis of asthma, the approach to establishing the diagnosis, and the tests that may be employed in confirming the diagnosis. Recommendations are provided for when to refer to an asthma specialist for a consultation or for ongoing care. The chapter also describes the goal of therapy in asthma and recommends methods for monitoring asthma, along with specific strategies to improve asthma care and to enhance communication between the health care provider and the patient. Much of the content comes directly from the recent Guidelines for the Diagnosis and Management of Asthma developed by the National Institutes of Health (NIH)-NHLBI National Asthma Education and Prevention Program (1). Other recent NIH publications that may provide a valuable resource for the clinician are listed (2-8).     

Management of asthma exacerbations

The 1997 Expert Panel Report 2 from the National Asthma Education and Prevention Program* details principles and goals for managing asthma exacerbations, based on scientific literature and the opinion of the panel. The panel's recommendations are summarized here, along with approaches to the evaluation and management of patients with asthma exacerbations. Methods to assess and classify the severity of asthma exacerbations are discussed, and treatment objectives for mild, moderate, and severe exacerbations are presented, along with a discussion of postinfectious acute airway hyperresponsiveness. A review of pharmacologic agents used in the treatment of asthma exacerbations is also included. Key points in the management of asthma exacerbations include the notion that early treatment is the best strategy for management. Important elements of early treatment include recognition of early signs of worsening asthma, a written action plan to guide patient self-management, appropriate intensification of therapy, and prompt communication between patient and provider about deterioration in asthma control. Other key points include the use of inhaled beta 2-adrenergic agonists to provide prompt relief of airflow obstruction, the early use of systemic corticosteroids for patients with moderate to severe exacerbations or for patients who fail to respond promptly and completely to an inhaled beta 2-adrenergic agonist, and monitoring response to therapy with serial measurements of lung function.     

Management of asthma exacerbations

The 1997 Expert Panel Report 2 from the National Asthma Education and Prevention Program details principles and goals for managing asthma exacerbations, based on scientific literature and the opinion of the panel. The panel's recommendations are summarized here, along with approaches to the evaluation and management of patients with asthma exacerbations. Methods to assess and classify the severity of asthma exacerbations are discussed, and treatment objectives for mild, moderate, and severe exacerbations are presented, along with a discussion of postinfectious acute airway hyperresponsiveness. A review of pharmacologic agents used in the treatment of asthma exacerbations is also included. Key points in the management of asthma exacerbations include the notion that early treatment is the best strategy for management. Important elements of early treatment include recognition of early signs of worsening asthma, a written action plan to guide patient self-management, appropriate intensification of therapy, and prompt communication between patient and provider about deterioration in asthma control. Other key points include the use of inhaled beta 2-adrenergic agonists to provide prompt relief of airflow obstruction, the early use of systemic corticosteroids for patients with moderate to severe exacerbations or for patients who fail to respond promptly and completely to an inhaled beta 2-adrenergic agonist, and monitoring response to therapy with serial measurements of lung function.     

Process improvement for asthma. An integrated approach

At least 18 million people in the United States have asthma. Despite the publication of national guidelines, the delivery of care has not substantially changed. This article describes a program at Chicago city sites to improve the delivery of care to adults and children with asthma. Using consistent comprehensive patient education materials, innovative provider education, and a variety of continuous quality improvement interventions including creation of a designated practitioner, this project enhances partnership between patients and health care providers.     

Critical care medicine update

The intensive care unit (ICU) can be a challenging environment for health care practitioners who are not trained in critical care medicine. A structured approach to patient care is necessary in order to achieve optimal clinical outcomes. The purpose of this two-part article is to review essential highlights of critical care medicine for the nonintensivist. We provide a structured overview of the management of the critically ill patient and focus on problems commonly encountered in the heterogeneous ICU patient population. In Part 1 we review (a) altered states, of consciousness and sedation, (b) respiratory failure and ventilators, (c) cardiovascular monitoring and management, and (d) fluid and electrolyte disorders. This authors have stated that they do not have a significant financial interest or other relationship with any product manufacturer or provider of services discussed in this article. The authors do not discuss the use of off-label products, which includes unlabeled, unapproved, or investigative products or devices.     

A review on adherence management in patients on oral cancer therapies

PurposeThere is currently an ongoing paradigm shift in cancer treatment from intravenous (IV) chemotherapeutics to oral therapies. Additionally, the increased use of long-term maintenance therapy with oral targeted agents or chemotherapy is contributing to a shift toward a chronic-disease model. This shift is creating challenges and responsibilities for health care professionals in patient adherence management. This article will inform health care professionals of current trends and describe ways that they can overcome common barriers to adherence. A comprehensive review of recommendations and evidence derived from oncological studies describing adherence to oral targeted therapies and maintenance chemotherapy will provide guidance for the use of emerging oral maintenance therapies.MethodsArticles in the scientific literature were reviewed if published between January 1985 and November 2010. Searches were conducted using the PubMed database—search terms included “oral therapy,” “chemotherapy,” “cancer,” and “adherence” or “compliance.”ResultsThe change from IV therapy administered and monitored in hospitals or clinics to self-administered outpatient oral treatments decreases the likelihood of adherence. Methods, such as patient education and monitoring and involvement of family or caretakers, can improve adherence in patients undergoing treatment.ConclusionsAt treatment onset, oncology nurses can engage patients directly in a collaborative dialogue, and when issues affecting adherence arise, oncology nurses may limit nonadherence by providing individually tailored educational material. A practical approach to patient education, along with building strong health care provider–patient relationships, can help patients overcome nonadherence to new oral anticancer therapies and treatment paradigms.     

Asthma care of children in clinical practice: do parents report receiving appropriate education?

This paper describes asthma education received from the health care provider as reported by parents of children with asthma and evaluates differences in their report based on socio-demographic and disease characteristics. Methods: Parents of 228 children with asthma were recruited from diverse clinical practice sites and asked to report on the level of education received in key content areas the National Asthma Education and Prevention Program identified as critical. Results: The overall proportion of education content fully discussed was 66%. Areas that dealt with acute management (how to manage an asthma attack: 75%) and medication administration (how to use an MDI: 81%) were most likely to be discussed. Content dealing with ongoing chronic management and collaborative care planning (discussing goals of management: 44%; providing written guidelines for acute management: 44%) was significantly less likely to be discussed. Education reported differed significantly based on symptom severity and socio-demographic characteristics. Parents of children with moderate to severe persistent symptoms reported receiving more education than those of children with mild symptoms (p < .05). Minority and poor parents, parents with less education, and parents whose children received health care in a clinic practice setting reported more education received than did their counterparts (p < .05). Summary: Significant gaps exist in education received overall, and specifically in areas associated with developing a collaborative relationship between parent and health care provider. The initial observation of socio-demographic differences in education reported has implications for pediatric nurses involved in asthma education and warrants further investigation.     

A framework for fibromyalgia management for primary care providers

Fibromyalgia is a chronic widespread pain disorder commonly associated with comorbid symptoms, including fatigue and nonrestorative sleep. As in the management of other chronic medical disorders, the approach for fibromyalgia management follows core principles of comprehensive assessment, education, goal setting, multimodal treatment including pharmacological (eg, pregabalin, duloxetine, milnacipran) and nonpharmacological therapies (eg, physical activity, behavioral therapy, sleep hygiene, education), and regular education and monitoring of treatment response and progress. Based on these core management principles, this review presents a framework for primary care providers through which they can develop a patient-centered treatment program for patients with fibromyalgia. This proactive and systematic treatment approach encourages ongoing education and patient self-management and is designed for use in the primary care setting.     

Shared decision making in school age children with asthma

Shared decision making in health care is a mutual partnership between the health care provider and the patient. Traditionally, children have had little involvement during their medical care visits or in decisions regarding their health care. Shared decision making in children with asthma may enhance their self-confidence as well as improve their self-management skills. Allowing the child to participate during the visit requires assessing the child's competence at different ages and abilities. Specific communication techniques to use with children during medical encounters include visual aids, turn-taking, clarifying communication, and role modeling. Providers additionally can offer strategies to parents on how to provide general information about asthma and treatments based on the child's questions and interest. The goal for school age children with asthma is to change dyadic interactions between the provider and parent into triadic interactions to improve the child's asthma management.     

Bipolar disorder: etiology, diagnosis, and management

PURPOSE: To review the epidemiology and disease characteristics of the bipolar disorder (BD) spectrum, render an accurate and timely diagnosis, and review treatment options through provider and patient collaboration. DATA SOURCES: Comprehensive review of current scientific literature derived from electronic databases and professional medical references. CONCLUSIONS: BD is a multifactorial disease that can interfere with cognition and behavior, causing a severe impact on patients and families. The variable course and often delayed diagnosis of this disorder can cause frustration for the patient and the healthcare provider. Because most undiagnosed patients with BD seek treatment within the primary care setting, it is imperative that clinicians become expert in the recognition of and intervention for this condition. IMPLICATIONS FOR PRACTICE: The primary care provider is in a key position to render early diagnosis and treatment of BD. This disease should always be considered as part of the differential diagnosis for depression or anxiety. Nurse practitioners can be effective providers by using good nursing practices of communication, education, and advocacy for the patient and family. Knowledge of current diagnostic criteria and management is imperative for successful treatment of patients with BD.     

Optimizing chronic obstructive pulmonary disease management in primary care

Diagnosis of chronic obstructive pulmonary disease (COPD) in primary care is complex, as many clinical symptoms are similar to asthma and heart disease, which may lead to misdiagnosis and suboptimal disease management. Spirometry is the best method for diagnosing COPD and distinguishing between COPD, asthma, and cardiovascular diseases. Airway obstruction is fully reversible in asthma, but not in COPD, and can be confirmed when the postbronchodilator ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) is <0.7. Knowledge of COPD treatment guidelines and a proactive attitude toward disease management by primary care physicians are key to improving symptom control and patients' quality of life. Identification of the appropriate drug/inhaler combination, patient education, training on inhaler use followed by regular monitoring, and pulmonary rehabilitation are also vital to successful COPD management. This review outlines steps to aid physicians in devising and implementing an optimal management plan for COPD patients.     

Patient-Centered Care for Childhood Asthma

Asthma, the most common chronic disease in children, is characterized by chronic inflammation of the respiratory system. If left uncontrolled, persistent asthma can have serious negative clinical outcomes. Thus, the earliest possible diagnosis based on the recognition of specific clinical indicators, treatment with anti-inflammatory controller medications such as an inhaled corticosteroid (ICS) or a leukotriene receptor antagonist (LTRA), and patient-centered strategies for monitoring disease and improving patient adherence are essential to successful asthma care. Recent clinical studies support the efficacy of ICSs over LTRAs as daily treatment for pediatric asthma. Routine follow-up and patient education can facilitate adherence to daily controller therapy and successful asthma control in children.     

Translating ADA/EASD Guidelines and the ACE/AACE Road Maps into Primary Care of Patients with Type 2 Diabetes

Optimal glycemic control is fundamental to diabetes management. New diabetes guidelines suggest that recommended glycated hemoglobin (A1C) targets for Type 2 diabetes can be, for most patients, achieved through a stringent, multi-pronged, multi-disciplined approach comprising early and focused intervention, regular monitoring, timely changes to medication, early use of combination therapy, early use of insulin, and patient empowerment through education. Using examples from real-life patient care, the implementation of these guidelines is reviewed from the perspective of the advanced practice nurse.     

Treat-to-Target Approach in Inflammatory Bowel Disease: The Role of Advanced Practice Providers

Updated therapeutic guidelines for inflammatory bowel disease call for effective disease assessment, early intervention, and personalized patient care using a treat-to-target (T2T) approach. The ongoing, intensive monitoring of a T2T strategy is best facilitated by a multidisciplinary team, but the increased demand on health care systems impedes implementation. Therefore, advanced practice providers have a growing role in bridging the gap between T2T recommendations and clinical practice. Advanced practice providers can effectively facilitate patient-care team communication, deliver patient education, perform in-clinic and remote monitoring of symptoms and treatment response, and assist patients with self-management.     

Early Palliative Care Initiation: Role of the Primary Care Clinician

Palliative care provided to patients with chronic life-limiting illnesses shows improvement in symptom management, quality of life, and caregiver support while reducing cost of care. Early initiation of palliative care faces a multitude of barriers in the primary care setting, including provider confidence, coordination and implementation, education, and family and patient misconceptions. A team-based approach along with additional education, clear referral triggers, and resources for advanced-care planning discussions allows providers to overcome many of these barriers. With the population’s advancing age, it is essential that primary care providers are properly prepared for early initiation of palliative care.     

Asthma self-management patient education

Asthma self-management education involves a collaborative partnership between the education provider and the patient. An asthma action plan facilitates asthma self-management and improves patient outcomes. The 2007 asthma guidelines from the National Asthma Education and Prevention Program emphasize that respiratory therapists, nurses, pharmacists, and physicians should teach and reinforce asthma self-management education at every opportunity and in all settings.     

Is home peak expiratory flow monitoring effective for controlling asthma symptoms?

A case in which a home peak expiratory flow (PEF) monitoring device was recommended led us to review the evidence examining this intervention. The clinical question to be answered was: should these devices be consistently recommended to all patients with asthma? A comprehensive search revealed eight randomized controlled trials, one review and one consensus report. Four trials provided all subjects with asthma education and compared patient-specific action plans based on symptoms to those based on PEF readings. Four trials compared usual asthma care to peak flow monitoring (PFM) and varied in both their content and intensity of asthma education. Six out of eight studies showed improvement in some selected markers of asthma morbidity with home PFM-based action plans. Improvements were also observed in patients using a symptom-based action plan. These studies did not demonstrate any obvious advantage of PFM compared with symptom-based monitoring but did suggest that a monitoring plan with predetermined actions based on PEF measurements or symptoms can lead to improved asthma control. Although not specifically studied, PFM may be more appropriate and effective for patients who have difficulty identifying worsening of asthma control through symptom monitoring.