Nursing

Nursing Lianyungang, 23. 7.2018 Martin P. Wedig

Contents • I NURSING • 1. Definition and position of nursing within a process • 2. traditional nursing • 3. Scientific evidence for effects of nursing • 4. New roles of nurses • 5. Finding a concept • II REHABILITATION

Definition and position of nursing within a process

Definition • Rheumatic diseases are diseases of joints and tissues, that are not caused by injuries but initiated and prolongonged by inflammation. • Organs and vessels may be involved visable by symptoms or this involvement may be covered by the predominent joint complaints.

• Nursing is the intervention for disease by experts on an equal stage level to other disciplins within a planful procedure for the stabilization of rheumatic diseases.

Definition • The Multidisciplinary Team can be difficult to define. • The definition is half open and can not to be restricted to • - rheumatologists • - primary care providers • - nurses • - rehabilitation specialists • - physical specialists •…

Patient

Planning

stuff

goals

monitoring

From: British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Rheumatoid Arthritis (the first two years) Rheumatology (Oxford). 2006;45(9):1167-1169. doi:10.1093/rheumatology/kel215a Rheumatology (Oxford) | © The Author 2006. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org



Function of a Nurse specialist • Nurse specialists are advanced nurses, that collaborate with interested/specialized General Practioners. • Their role is the treatment alternatively to an early synovitis hospital or an rapid access clinic (in Great Britain)

traditional nursing between teams and protocols

Core problem of the patient • The painful swollen joints aren‘t moved in the physiological way. • This leads to – transient stiffness • - contractures • - deforming of the habit of these joints

Attended problems • The reduced activity during the active phase of inflammation increases the handicaps. • The patients need help for daily activities. • During the inflammation young patients show handicaps at the level of seniors. • A longer time of not controlled inflammatory activity causes damage in organs: loss of pulmonary function, progression of cardiovascular diseases. • Nearby low activity kills by pulmonary infections.

Evidence for attended problems Causes of death

Kasitanon 2006

Feng & Hu 2016

Infection

44%

30,1% (1/3 pneumonia)

Cerebrovascular events

12%

14,8%

Cardovascular events

10%

Renal failure

14,4%

There seems to be a progress of 10% on infectious causes of mortality of rheumatic diseases. Yet the comparison between countries is limited. There subcategories missing. The equal rate of cerebrovascular events might point out to similiar conditions of the two study populations.

Reducing pulmonary infections • A reduced rate of overall infections might indicate progress in activating nursing: • Training of movements (activ, passiv, activ assisted) • Sitting dancing • Walk around • Training of small duties: sorting the cutlery

Nursing on stiffness • Joints should rest in a physiological position • Nursing should obey the morning stiffness: start procedures 1 h after the stiffness has vanished • Motivate the patients to help themselves • Give early pain reducing medicament to the meals • Watch and protocol pain • Give warm treatment

Use of physical treatments • In 2014 the ambulant use of physical treatments on Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriatic Arthritis, Lupus erytematosus was evaluated in Germany.

• • • •

Disease

Physical Therapy

AS

47%

RA

26%

PsA

24%

Lupus erytematosus

14%

Since 2008 the frequency of these treatments in unchanged. According 1996-2004 this frequency was reduced. Economic determines doctor‘s prescreption. SPD party of FRG demands therefore nurse license or even self license for presription of physical therapy.

Nursing connects demands of the patient

Scientific evidence

Negativ evidence • There is recent evidence, for the uselessness of phyisical treatment for the finger grip and the traction power of the fingers (German study with a small group of patients 2018). • Yet this are not the efforts, that rheumatic patients have to do.

• Such studies argue for the perpetuation of the sparing prescreption measured by historical quotes.

Positiv evidence: clinical nurse specialist • Care provided by a clinical nurse specialist appears to have a similar clinical outcome in comparison with inpatient and day patient team care. [Arthritis Care & Research Volume 47, Issue 5] • Compared with inpatient and day patient team care, clinical nurse specialist (CNS) care was shown to provide equivalent quality of life and utility, at lower costs. [BMJ 62(4)] • Care provided by a CNS in an outpatient rheumatology clinic has a similar long‐term clinical outcome to inpatient and day patient team care in patients with rheumatoid arthritis. [Journal of Advanced Nursing Volume 41, Issue 1]

Positive evidence for Nurse Led Care • The results provide robust evidence to support non-inferiority of Nurse Led Care in the management of RA. [Ann Rheum Dis 73(11)] • While few outcomes favoured nurse-led care, there is insufficient evidence to conclude whether this is the case. More good quality RCTs of nurse-led care effectiveness in rheumatoid arthritis are required. [Int J Nursing Studies 2011 (48): 642-654]. • It is safe to implement shared care and nursing consultations as alternatives to rheumatologist consultations for RA outpatients with low disease activity without deterioration in disease control. [http://dx.doi.org/10.1136/annrheumdis-2012-202695]

Patient education • Effectivenss studies show different outcomes for: - Pain reduction - Improved self management - Improved coping - Self-efficacy (a belief that you can do a task) - [Hochberg: The patient perspective. 2018]

New roles of nurses

EULAR recommendation for the role of nurse • 10 recommendations were formulated. • 7 recommendations covered the contribution of nurses to care and management: education, satisfaction with care, access to care, disease management, psychosocial support, self-management and efficiency of care. • 3 recommendations focused on professional support for nurses: availability of guidelines or protocols (1), access to education (8) and encouragement to undertake extended roles (9)

Transliteration of ABCD Strength of Recommendations Strength

Natural speaking A

must

B

Should

C

could

D

To be considered, If no better information Is avaiable

EULAR A-recommendations • 1. Patients should have access to a nurse for education to improve knowledge of CIA and its management throughout the course of their disease • 2. Patients should have access to nurse consultations in order to experience improved communication, continuity and satisfaction with care • 4. Nurses should participate in comprehensive disease management to control disease activity, to reduce symptoms and to improve patient-preferred outcomes • 5. Nurses should identify, assess and address psychosocial issues to minimise the chance of patients’ anxiety and depression

Demands • It also seems justified to say that nursing care should especially focus on older people and that these people should be assessed for their level of pain, functional limitations and QoL especially in the case of having rheumatoid arthritis and/or osteoarthritis. [Journal of Clinical Nursing Volume 11, Issue 4]

British recommendations • 8. ALL patients should be provided with a patient-held booklet of their DMARD monitoring records with clear mention of all current results where appropriate. • 9. Extra caution is required before advising patients about immunizations, as live vaccines are not recommended when patients are on certain immuno modulators. • 10. All patients should ideally be made go through a regular educational programme before prescribing the DMARD. • 11. …for the purpose of monitoring should be taken as an opportunity for teaching and training about the role of the DMARD in RA or other similar diseases.

Comparison of concepts • EULAR Recommendations • 1.+2. Nurse for education

• 4. comprehensive disease management

• 5. psychological issues

• Great Britain Guideline for RA • 11. opportunity for teaching • 10. regular educational programm

• 9. self management programme

Finding a concept

Nurse for Education Comprehensive Management

Eular Psychological Issues

Patient education Great Britain

Regular educational Program

Self Management Program

Comparison of Concepts by literary text analysis • EULAR discusses the new role of a nurse. • EULAR targets management of disease. • Great Britain has an real Advanced Praxis Nurse since 2006. • Great Britain enhaces educational programs. • Link and differences are psychological impacts and patient‘s selfmanagement.

Implementation of nurse specialists

Nurse specialists

2 positions within a process

Patient‘s education

Development of professional roles Regulare care of indoor patients

Traditional role of a nurse

Education of indoor + out patients Developing role of a nurse Preparing

Nurse specialist for out patients Alternative treatment instead of quick access clinics

Advanced Praxis Nurse Ready for action

Advanced Praxis Nurse

Nursing drives the wheel of patient centered care Organization of care

Self management

Multidisciplinary team

Patient centered care

Shared decision making

Patient education

Advanced Praxis Nursing (APN) • APN is an umbrella term for various roles of nurses • Definition (Int Coucil of nurses) of a APN role: “registered • nurse who has acquired the expert knowledge base, complex • decision-making skills and clinical competencies for expanded • practice, the characteristics of which are shaped by the context • and/or country in which s/he is credentialed to practice

Actual actions in China Recently, four strategic directions and actions were proposed by the China Medical Board China Nursing Network: • 1. standards for advanced nursing practice • 2. master's level curricula • 3. pilot projects across a number of university affiliated hospitals • 4. prepare clinical tutors and faculty

Submit Your paper • International Journal of Nursing Sciences • Copyright Holder: Chinese Nursing Association Production and hosting by Elsevier B.V. On behalf of Chinese Nursing Association • Source Normalized Impact per Paper (SNIP): 0.473

Rehabilitation

Stage dependent features Early Stage RA

Progressive Stage RA

Prevention of stiffness

Detection of typical signs of activity • Pitting edema

• Joint effusion

Stage dependent differences Early Stage RA

Progessive Stage RA

• Pain management • Physiotherapy • Rehabilitation for job and familiar function

• Pain Management • Physiotherapy • Rehabilitation for activities of daily life

Early Stage RA

• Nursing: Education • Physiotherapy: Warm applications • Training • Ergotherapy: Joint protection • Psychology: Coping • Rehabilitation: Job saving actions • Helping the family

Progressive Stage RA

• Nursing: help and care • Physiotherapy: Warm applications • Orthotics: joint stabilization • Ergotherapy: teaching new techniques • Psychology: Coping • Rehabilitation: for activities of daily life

4 joints = Oligoarthritis

Symmetric swelling of MCP 2+3

Soft welling

Handicap of hand function

A married person

Help for the family

Level of pain

Summary • Traditional Nursing is a concept of hospital based care. • Generalized Nursing in Rheumatology has at least two foci: 1 . ambulatory early treatment 2. team based treatment in a line of experts

Knowledge of borders and chances • Results: • No improvement ot the force of the hook-grip up to the level of healthy persons • Improvement of the force of the hook grip: +12% • Lowering of the force of the top grip by kryotherapy • The analysis of the function of the hand is necessary for a functional diagnosis of rheumatoid arthritis.

• Mucha, C.: Der Einfluß analgetisch wirkender physikalischer Thereapieformen auf spezifische Fingerkräfte von Patienten mit rheumatoider Arthritis. Die Naturheilkunde. 2018; 3: 18-20.

Mention options for Chinese Medicine • Treatment of Bi-Syndromes • • • •

Anemarrhena (Guizi shaoyao zhimu tang) Aconitis (Wutou tang) Notopterygium (Qianghuo shengshitang) Take-9-Notopterygium (Jiuwei qianghuo tang)

• „Professor Shen Pi‘an Notopterygium + Rehmannia (N+R) was comparable effective with MTX and showed less adverse events. Anti-CCP-antibodies lowered. After 48 weeks N+R was superior against MTX.“

• Hambrecht, K.: Chinesische Medizin bei Rheuma und Gelenkbeschwerden. Die Naturheilkunde. 2018; 3: 22-24

Role description March & Richards „Treat to Target“ • Nurse has a primary care role in explaining and demonstrating medication use, action, interactions, side effects, and medication administration devices. • Pharmacist provides patient education about the effects and side effects of drugs, how to read prescreption bottles and take medications, and when and how to modify drug regimens; monitors for possible drug interaction. • Physician explains the disease, its physiology, natural history, and the rage of therapy avaiable; the need for disease monitoring. • Rheumatologist defines start and switches.

Panel question: What is the most important ability of a designated APN? • Communication skills: The nurse should show pedagogic experience and be able to give information to different graded adressees • Communication does not mean a simple test of vocabulary knowledge, orthography, style. Such tests are often misapplied. • Within the present programmatic for APNs there is no evidence based matrix analysis for the selection of candidates for the curricula. • Portfolio analysis might be a method for presention of the candidates by a mentor for proposal of his tutees to the support program.

APN gives uncomplaining explanations to increase adherence to therapy

Aims of therapy Treat-to-Target-Strategy Reliance to concept Demand at least patient‘s training for self-scoring and time-dependent decision-making