Common Health Problem and Recommendations for Its Medical Management

NP HEALTH PROBLEM
Common Health Problem in Primary Care Nurse Practitioner Practice and Recommendations for Its Medical Management
Nurses are the initial point of contact for the patients in many medical settings, and the nurse practitioners (NP) are the primary source for providing basic medical care such as physical examinations, diagnostic tests, providing counseling, and writing prescriptions. A large growth is being witnessed in nurse practitioners around the world due to the arising pandemics; however, they have been of great help in usual health cases since they function in institutes like clinics, hospitals, schools, and workplaces. As they are the first initial source of medical care for the patients, they are the first-hand problem solvers since they have to guide them according to their medical requirements. This paper analyzes a common health problem faced by NPs and would recommend medical management for it. In further sections, the problem would be deeply analyzed for evaluation and providing suggestions.
Healthcare Problem Identified
Asthma inhalers are a source of relief for asthma patients since they are breathed directly into the lungs for the prevention of symptoms of this disease. The correct usage of inhalers is crucial for controlling the disease, and various studies have shown that patients were unable to use the asthma device incorrectly, causing uncontrolled asthma. Repeated education is needed; this should include physical demonstrations of the inhalers, checking if the patient's technique is workable, correcting the technique, and rechecking for its effectivity. It was also observed that trained staff id required for better instructing of the patients, and for this purpose, nurse practitioners play an important part. Additionally, the choice of the inhaler should depend on the cost-effectiveness, whether the patient can afford it or not so that he should be able to use it correctly and enhance its compliance.
A study indicated that metered-dose inhaler (MDI) had the most frequent number of errors; in terms of coordination, 45 percent, speed, and depth of inspiration 44 percent, no breath-hold after inhalation 46 percent (Sanchis, Gich & Pedersen, 2016). Even dry powder inhalers (DPI) were checked for errors too, which revealed that incorrect preparations accounted for 29 percent error, no full expiration before inhalation was 46 percent, and no holding of breath after inhalation was 37 percent. The general prevalence of the correct technique was 31 percent.
These problems occurred soon after metered-dose inhalers were launched. However, efforts were made to educate the patients about their usage. Nonetheless, there were still some patients who could not understand the particular method. The instruction methods included regular training programs, printed materials, videos, and software. Nurse practitioners also helped in the first-hand instructions to make it easier for them, including both children and adults.
Chronic obstructive pulmonary disease (COPD) together with asthma are the two of the highly ranked diseases in the world that are leading causes of deaths of around 339 million people globally (Bhushan et al., 2018). It accounts for up to 1000 people dying each day, including both children and adults. COPD is the fourth leading cause of death and can go up in the rank in third place by the year 2020. Various studies have indicated that improper use of inhalers has led to an increase in asthma and COPD. Therefore hospital visits have surged as well. As it was noted that poor inhalation technique was the main reason for increased clinical visits, this was also because patients missed at least one serious step of the technique and had low literacy levels.
The poor technique has been linked to factors like age, sex, educational levels, and emotive problems (Milanese et al., 2019). Younger asthmatic patients have reported more mishandling of the device, which resulted in poor disease control. In older patients, COPD is more common but requires prescribed medication, including inhalers. High rates of poor device handling were also reported among these patients, inducing severe exacerbations.
In epidemiological terms, children have been more prone to this disease as compared to adults. Still, it would be difficult to reside upon these results since there have been different definitions of age for asthma status around the world (Dharmage, Perret & Custovic, 2019). For older people, the co-morbidity rates are hard to define since asthma symptoms could be related to breathlessness or COPD, inciting to heart failure. Environmental exposure at an early age, such as those among children, is the primary cause of early asthma. In utero parental smoking can provoke asthma in young children; studies have revealed that female smokers are more likely to have asthma as compared to non-smokers, but this data might not apply to men. Outdoor air pollutants are globally manipulating the quality of air inhaled by children and adults; thus, impacting heavily on asthmatic patients. Indoor allergens also should not be ignored since they have intense effects on asthmatic subjects. Occupational exposures are greatly affecting asthma patients since there are now two categories: work aggravated asthma (WEA) and occupational asthma (OA). Lifestyle factors, such as westernization and eating habits, have a command over asthma severity as well.
In pathophysiological terms, the rise in asthmatic cases is due to extra clean air conditions, especially in western culture, since it would expose them less to the environment and increase the infections. When they interact with the outdoor air, the chances of getting air pollutants into the lungs and upsetting the immune systems rise. Bronchiolar inflammation is bound to happen to produce less resistance against asthma. The inflammation hurts trachea and bronchi, accelerating an increase in mucus production and a decrease in mucus clearance.
Practice Guideline
The clinical practice guideline addresses the identified health problem, which is poor inhaler education among asthma patients. The guidelines focus on the pivotal diagnosis stage and the asthma management for devising bronchodilator therapies and keeping track of periodic measurements of lung functioning before and after the therapy (Amerigroup Real Solutions, 2016). This practice guideline is based on current evidence that is available within the last five years. It was published in the year 2016 in line with US data. The strength of this evidence is the detailed information provided about the aesthetic patients and precautions for them. Also, there are follow up plans once the asthma action design has been put to effect.
The practice guideline adequately directs the health care provider in the management of asthmatic interventions. There is a thorough description of the contributing factors for this disease, what triggers the patients and what methods should be used to avoid them, assessment and monitoring techniques are guided, pharmacotherapy is mentioned for better identification of individual's needs, and patient education plan, which is the basis of the problem identified in this paper.
The clinical guidelines clearly state management procedures for the health care provider that includes reducing impairment and maintain normal lung function. This is guided by maintaining normal activity levels, and this is only possible when risks are reduced. The associated risks could be diminished by avoiding exacerbations, lessening the requirement of emergency or in-patient care, stopping failure of lung function, for children preventing shrinkage of lung growth, and lowering negative outcomes of the therapy.
The performance of the clinical guidelines in the management of athematic patients is evident since combination and assessment of clinical therapies under the guidelines have improved the accuracy of asthma severity assessment (Dima, De Bruin & Ganse, 2016). The link between the provision of medical care services and the recipients is critical. Since this link is provided by the nurse practitioners who are the initial contacts for the patients, they play a vital part in assessing asthma severity. Practice guidelines provide a meaningful direction to the practitioners for reviewing asthma severity and provide appropriate pieces of advice for better therapies, including inhaler use. The health care services can impact asthma controlling in two parts: stirring asthma management process directly through medical care and altering caregiver and patient behaviors through behavioral care. It is well known that the performance of these two parts, medical and behavioral care, can be influenced by the clinical guidelines so that health care professionals, such as nurse practitioners, directly mold the patients' control in the disease. The control can be brought if clinical guidelines shape the modifiable factors of health care providers, such as medical knowledge, communication skills, training methods, and treatment techniques. All the recommendations of these related sections are presented in the practice guidelines which nurse practitioners can make use of for better patient education for asthma control. However, there are non-modifiable factors, too, like the experience of the nurse practitioner, his gender, and age.
Educational interventions have been reported mitigating the outcomes of asthma in children and adult patients with an average follow up time of five months (Press et al., 2020). In the short term, the disease was controlled due to better educational techniques, either through physical demonstrations or sometimes virtual (V-TTG: virtual teach to goal) as well. Long term follow-ups were mainly held for those who consistently showed manhandling and poor disease control even after instructions being given. A guideline-recommended inhaler education was provided to the subjects through cost-effective virtual training. Inhaler techniques were examined using a 12-step checklist that was also in practice in the previous intervention studies.
The effectuality of patient management can be checked by numerous designs, including health technology assessment, which would help in examining what technology and thereupatic methods are best in delivering positive results for asthma patients. Randomized methods can be useful as well, which include random allocation of probers for assessing the efficacy of installed methods in the clinical setting based on the clinical guidelines. Virtual monitoring that includes video monitoring through surveillance cameras within the clinical premises would help know whether patient management is done productively. For the past ten years, mobile phone technology has been very valuable. In the future, it can create wonders for asthma patients in impactful management and monitoring of adherence to inhaler methods (Morton et al., 2020). Nurse practitioners can assess through mobile monitored video apps whether the patients are adhering to underlying steps of inhaler use and what step they are missing, which is responsible for uncontrolled asthma. Web-based programs or e-health can help assess the patients and their adherence to self-management policies. It provides a flexible forum for patients to come forward and discuss their issues, and this can be achieved via education, empowerment, and active participation of both the nurse practitioners and the patients.
Analysis
Taking into consideration the future health care needs of patients with poor inhaler education, the pivotal role of nurse practitioners could not be ignored. Training should be given to the nurses for correct techniques, which later should be transferred to the patients for overcoming symptoms of asthma. It is not wrong to assert that successful nurse education would reap fruitful results in disabling consequences for asthma patients. Training can be provided hospital-wide through one-on-one education methods, classes through the web, or unit-based education (Scullion, 2018). Placebo devices could be used for giving demonstrations to the nurse practitioners so that they get aware of the using techniques. Afterward, they could transfer this knowledge accurately to the patients. These devices would not be useful for nurse practitioners only but also for the patients so that they get familiar with their use beforehand. Nurse education should also include getting aware of all the new medications in the market and what medicines are obsolete so that when an asthma patient comes in for urgent help, he could be prescribed with up-to-date medications.
In the future, there is a demand to check whether the inhalator's use and their methods are properly utilized by the asthma patients to control the disease. For this purpose, there are many tools to aid patients in precise inhaler handling. In-check DIAL allows the health care specialists to train patients about the inhalers as it assesses the peak inspiratory flow. There is another device called Trainhaler used for training patients on the same grounds; though, it has an additional feature that its mouth-piece, called Flo-Tone, can be changed for each individual as it is convenient for multi-patient usage.
The future health care needs of asthma patients also require the nurse practitioners to be aware of the religious or cultural concerns while using an inhaler. This means some populations might not be able to use inhalers due to some extent of alcohol mixed with the medication. Moreover, some cultural beliefs hinder them from using inhalers as they take it as impolite or a type of oral drug. Some studies have shown that mothers of asthmatic children have been apprehensive of the use of drugs or inhalers for their children since either they were not completely comfortable with the medical system or they were unsure of the chemical formulation of the inhalers.
With the emergence and increased need for e-health, asthma control requires smart inhalers, which would allow the patients to connect with the help of Bluetooth connectivity and collect data by a health app or website. This could be accessed later by the patient (self-management), his nurse practitioner, or specific asthma doctor to whom he regularly visits. Furthermore, these inhalers allow the patient to set reminders for taking medications, and enablement of efficiency can be monitored as well. Technology should be considered seriously regarding asthma control since it helps in making healthcare more tailored, reachable, and acceptable to patients.
Changes in global demographics are bringing changes to the US as well that would directly affect the clinical practice guidelines and healthcare within the country. For instance, Millennials (people with ages 23 to 28) would increase in number as compared to Baby Boomers (ages 55 to 73). Still, there is a greater population, Generation Z, maturing to adulthood (Cilluffo & Cohn, 2019). Millennials are more educated, leading to the fact that high literacy would bring high education about inhaler use and fewer mistakes, resulting in lower asthma cases. Generation Z is arguably the most ethnically diverse and most educated generation by far, hence, assuming to be more informative about inhaler use. Forty-eight percent of Generation Z people are racial or ethnic minorities and are expected to be the largest US racial group casting votes. This huge category of voters would help in framing the healthcare system of the country, directly influencing the clinical guidelines.
Changes in family patterns are highly evident; the unmarried parents living with a child has increased from 7 percent to 25 percent. US children living with unmarried parents are now 32 percent, which was 13 percent back in 1968. Stay-at-home parents represent 18 percent of the US population. These facts show that children who would be cared for and monitored by their parents regarding asthma control would be fashioned accordingly. The clinical guidelines have to be designed accordingly so that guidelines include the role of parents in controlling asthma in young ones. The immigrants in the US have been increasing rapidly but remain low as compared to other countries. This means that the inclusion of people from a variety of cultures and religious beliefs would be entering the US, thus forcing the country to revise its clinical guidelines. Household income is highest in recent years in the US, and this is more apparent in some racial groups. This could pattern the use of inhalers since rich people would be more likely to opt for more advanced and expensive medications for asthma control, thus aiming at lower disease prevalence. Clinical practitioners can guide these people regarding the most suitable medications that they can afford and adhere to.
Changes in healthcare policies also greatly imply how asthma patients take medications and what health care insurance plans they have to utilize. For case in point, with the new Affordable Care Act (ACA), the protection for asthma people still exists, but they have to look for medicines that are listed on that plan; only those supplements would be free of cost. This means if one medication suits them but is not listed in free coverage, then asthma patients would have to buy it from the appointed shop.
If clinical guidelines were to be revised, the changes could be based on the above-mentioned shifting world demographics, which would consequently influence the US health care trends. These could be used as evidence for revising the practice guidelines. Three basic changing drifts- an aging population, increased ethnicity, and urbanization- would outline the way nurse practitioners would have to intervene for better provision of support to asthma patients for inhaler education. If practice guidelines were to be changed based on the aging population, then it should be kept in mind that prolonged ages would lead to asthma care over several years. Besides integrating traditional practice guidelines about inhaler education, the use of smart apps would be beneficial. The clinical guidelines should include education about such apps, for all age groups encompassing Baby Boomers, Millennials, and Generation Z. Clinical guidelines should be revised for increased ethnicity since immigrants have largely grown in numbers within the US, and people from different cultures are entering the states. Practice guidelines should cater to the religious and cultural aspects of ethnic asthmatic patients so that inhaler use should take into consideration whether or not it contains alcohol or is deemed inappropriate for oral use.
Additionally, if Hispanic people are coming into a region, they might feel comfortable talking to a Hispanic doctor. So, hiring of culturally competent practitioners should be considered for inhaler education of asthmatic patients; their recruitment in the healthcare workforce and training is a grave need of current times. Clinical guidelines should be revised for rising urbanization since people's lifestyles and eating habits would be changed. Highly educated individuals would be increasingly aware of inhaler use; hence, asthma could be controlled.
Nevertheless, if they are living in urban areas, there is more likeliness that the areas would have more vehicles and more air pollution; therefore, triggering of asthma is inevitable. For such patients, clinical guidelines should include self-management techniques such as knowing one's trigger points, knowing the medications and dosage, being familiar with the inhaler device, and steps involved in inhaler use. Individuals living in urban regions would be more alert to the technological methods for checking their asthma symptoms and should be in constant contact with their nurse practitioner with the monitoring apps.
The methods that might be utilized to increase the likelihood that new amended clinical practice guidelines are adopted include, to begin with, hiring of culturally competent nurse practitioners. They would hold empathetic discussions with the patients. They would take asthmatic patients into confidence so that they share their backgrounds and the history of their ailment. Practitioners should also discuss with them how culture strikes the use of medications and, in such cases, what medications would be best suited for them. With the help of demos and constant coaching, use of inhalers would be implanted in the minds of patients even if they are reluctant. Secondly, emphasizing the use of technology for reminding about the medications and self-monitoring is of vital significance. In today's world, even the simple tasks are now simplified with the use of technology, and smart apps would be of great benefit in tracking asthmatic patients' timely intake of inhalers and medications. The patients would not only be connected with their doctor but also with the pharmacies so that in-time deliveries of their supplies are possible. Education about the use of those apps would also be included in these strategies.
Evaluation
An evaluation for determining the effectiveness of revised clinical guidelines is important since it would identify how helpful the newly implemented guidelines are in inhaler education and asthma control.
i. Firstly, shared decision making is quite helpful since with the help of nurse practitioners; the patients can discuss their health issues along with asthma, and their trigger points.
ii. The practitioners will get to know what cultural and language barriers can the patient face and try to resolve them with shared decision making. The practitioners should also speak slowly and in the teach-break method to let the patient understand the instructions in simpler language. This would be greatly helpful for culturally diverse patients.
iii. Individualized self-management plans should be generated with the mutual consent of the patients, and the inhalers should be selected based on affordability and adherence. Adherence is only possible if patients know all the necessary steps in their usage, and that is only workable through proper education given by practitioners.
iv. It should be made mandatory for the patients to install smart apps on their phones, which would remind them of their medication times and would be worthwhile in contacting practitioners or contact the pharmacies for a refill of their finished medical supplies.
v. Sharing data between different departments of the healthcare is important so that if an asthma patient does not buy medications or inhalers for a particular month, the hospital pharmacy should notify the appointed doctor for that patient, and the doctor would then reach him for discussing reasons for non-adherence to the medical plan.
vi. Moreover, this data interoperability would be necessary for measuring achieved outcomes through quantifying of readmission rates for asthma patients.
Learning Points
Few learning points from this case are mentioned as follows:
· Inhaler education is imperative for lessening asthma in both young and old patients. For this purpose, nurse practitioners play a major role since they are the first contact points for the patients to seek advice.
· Cultural diversity, urbanization, and changing health care policies should be kept in mind for devising clinical guidelines, and how the patient should be treated or prescribed inhaler types based on their cultural and religious beliefs should be of utmost importance.
· One cannot emphasize enough on the inclusivity of technology for monitoring and following up on the patients for asthma control.
References
Amerigroup Real Solutions. (2016, July 16). Clinical practice guideline: Asthma.https://providers.amerigroup.com/ProviderDocuments/GAGA_CPG_AsthmaCMO.pdf
Bhushan, B., Singh, K., Abraham, J., Goyal, D. & Chungath, J.T. (2018). Evaluation of inhaler technique amongst asthmatic and COPD patients attending a tertiary care hospital. Journal of Medical Science and Clinical Research, 6. DOI:  10.18535/jmscr/v6i12.101
Cilluffo, A. & Cohn, D. (2019, April 11). 6 demographic trends shaping the US and the world in 2019. Pew Research Centre. https://www.pewresearch.org/fact-tank/2019/04/11/6-demographic-trends-shaping-the-u-s-and-the-world-in-2019/
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Morton, R.W., Elphick, H.E., Craven, V., Shields, M.D. & Kennedy, L. (2020). Aerosol therapy in asthma- why we are failing our patients and how we can do better. Frontiers in Pediatrics, 8(305). DOI: 10.3389/fped.2020.00305 
Press, V.G., Arora, V.M., Kelly, C.A., Carey, K.A., White, S.R. & Wan, W. (2020). Effectiveness of virtual versus in-person inhaler education for hospitalized patients with obstructive lung disease: A randomized clinical trial. Jama Network Open, 3(1). DOI:10.1001/jamanetworkopen.2019.18205
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