Dokumentiranje navodil o življenjskem slogu in samoobvladovanju bolezni pri pacientih s kronično obstruktivno pljučno boleznijo

Maruša Ahačič; Saša Kadivec; Jerneja Farkaš-Lainščak

doi:10.14528/snr.2018.52.1.184

Authors

Maruša Ahačič University Clinic of Respiratory and Allergic Diseases Golnik, Golnik 36, 4204 Golnik, Slovenia
Saša Kadivec University Clinic of Respiratory and Allergic Diseases Golnik Golnik 36, 4204 Golnik and Angela Boškin Faculty of Health Care Spodnji Plavž 3, 4270 Jesenice, Slovenia
Jerneja Farkaš-Lainščak General Hospital Murska Sobota, Ulica dr. Vrbnjaka 6, Rakičan, 9000 Murska Sobota and National Institute of Public Health, Trubarjeva cesta 2, 1000 Ljubljana, Slovenia

DOI:

https://doi.org/10.14528/snr.2018.52.1.184

Keywords:

documentation, hospitalization, patients, interprofessional collaboration

Abstract

Introduction: To achieve a better quality of life in patients with chronic obstructive pulmonary disease, these patients should be informed about the characteristics of the disease and measures for its effective selfmanagement. The aim of the study was to determine the frequency and type of written instructions regarding lifestyle and self-management of the disease in hospital documentation of patients with chronic obstructive pulmonary disease.
Methods: A retrospective quantitative study that reviewed all the hospital’s documents (therapy forms, nursing forms, archives of health education programmes, letters of discharge) was conducted including 253 patients with chronic obstructive pulmonary disease. The results were described in terms of descriptive statistics; chisquare test and ordinal logistic regression were used.
Results: On average, hospital records of patients with chronic obstructive pulmonary disease showed less than 4 instructions (x = 3.8, s = 5.1) about life style and disease self-management. Half of chronic obstructive pulmonary disease patients received letters of discharge (x = 0.5, s = 0.9) which contained less guidance about lifestyle and self-management of the disease than their hospital records (x2 = 33.455, p < 0.001). Nurses recorded the instructions five times more frequently than doctors.
Discussion and conclusion: The study showed a low number of written instructions about the life style and self-management of the disease given to chronic obstructive pulmonary disease patients during hospitalization. It is necessary to raise awareness about the importance of documenting health education instructions and design tools to improve inter-professional communication.

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Author Biographies

Maruša Ahačič, University Clinic of Respiratory and Allergic Diseases Golnik, Golnik 36, 4204 Golnik, Slovenia

dipl. m. s., mag. zdr. neg.

Saša Kadivec, University Clinic of Respiratory and Allergic Diseases Golnik Golnik 36, 4204 Golnik and Angela Boškin Faculty of Health Care Spodnji Plavž 3, 4270 Jesenice, Slovenia

asis. dr. , viš. med. ses., prof. zdr.vzg.

Jerneja Farkaš-Lainščak, General Hospital Murska Sobota, Ulica dr. Vrbnjaka 6, Rakičan, 9000 Murska Sobota and National Institute of Public Health, Trubarjeva cesta 2, 1000 Ljubljana, Slovenia

doc. dr., dr. med., spec. javnega zdravja

References

Almagro P. & Castro A., 2013. Helping COPD patients change health behavior in order to improve their quality of life. International Journal of Chronic Obstructive Pulmonary Disease, 8, pp. 335-45.

Carlfjord, S. & Lindberg M., 2008. Asthma and COPD in primary health care, qualitiy according to national guidelines: a cross-sectional and retrospecitve sudy. BMC Family Practice, 9 (36), pp. 1-6.

Documentation guidelines for registered nurses. 3rd ed. Halifax: College of Registered Nurses of Nova Scotia; 2012.

Effing, T., Monninkhof, E.M., van der Valk, P.D., van der Palen, J., van Herwaarden, C.L., Partidge, M.R., Walters, E.H. & Zielhuis, G.A., 2007. Self-management education for patients with chronic obstructive pulmonary disease. Review. Cochrane Database of Systematic Reviews, 17 (4), pp. CD002990.

Farkaš-Lainščak, J., 2010. Ocenjevanje vloge koordinatorja odpusta: primer obravnave bolnikov s kronično obstruktivno pljučno boleznijo. Specialistična naloga s področja javnega zdravja. Ljubljana: Katedra za javno zdravje, Medicinska fakulteta, Univerza v Ljubljani.

Farkaš-Lainščak, J., 2011. Promocija zdravja v bolnišnicah: od ideje o podpornih okoljih do razvoja Mednarodne mreže za promocijo zdravja v bolnišnicah. In: J. Farkaš-Lainščak & M. Košnik, eds. Promocija zdravja v bolnišnicah: strokovno srečanje ob ustanovitvi Slovenske mreže za promocijo zdravja v bolnišnicah. Golnik, 25. november 2011. Golnik: Univerzitetna klinika za pljučne bolezni in alergijo, pp. 4–13.

Harrison SL., Goldstein R., Desveaux L., Tulloch V. & Brooks D, 2014. Optimizing nonpharmacological management following an acute exacerbation of chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease, 9, pp. 1197-205.

Haynes, C.L., 2008. Health promotion services for lifestyle development within a UK hospital-patients' experiences and views. BMC Public Health, 13 (8), pp. 284.

Haynes, C.L. & Cook, G.A., 2009. An audit of health education services within UK hospitals. Journal of Evaluation in Clinical Practice, 15 (4), pp. 704–12.

Kaufmann, C., Markun, S., Hasler, S., Dalla Lana, K., Rosemann, T., Senn, O. & Steurer-Stey, C., 2015. Performance measures in the management od chronic obstructive pulmonary disease in primary care-a retrospective analysis. Praxis, 104 (17), pp. 897-907.

Kodeks etike v zdravstveni negi in oskrbi Slovenije in Kodeks etike za babice Slovenije, 2014. Ljubljana: Zbornica zdravstvene in babiške nege Slovenije - Zveza strokovnih društev medicinskih sester, babic in zdravstvenih tehnikov Slovenije.

Klijn SL, Hiligsmann M, Evers SM, Román-Rodríguez M, van der Molen T, van Boven JF, 2017. Effectiveness and success factors of educational inhaler technique interventions in asthma & COPD patients: a systematic review. NPJ Primary Care Respiratory Medicine, 27(1), pp. 24.

Make B& Belfer MH, 2011. Primary care perspective on chronic obstructive pulmonary disease management. Postgraduate Medical, 123(2), pp. 145-52.

Maciosek MV, LaFrance AB, Dehmer SP, McGree DA, Xu Z, Flottemesch TJ, Solberg LI, 2017. Health Benefits and Cost-Effectiveness of Brief Clinician Tobacco Counseling for Youth and Adults. Annalys of Family Medicine, 15(1), pp. 37-47.

Osterlund Efraimsson, E., Hillervik, C. & Ehrenberg, A., 2008. Effects of COPD self-care management education at a nurse-led primary health care clinic. Scandinavian Journal of Caring Sciences, 22, pp. 178–85.

Petek, D., 2010. Vodenje bolnika s KOPB in astmo v ambulanti družinske medicine. In: K. Tušek-Bunc, ed. 6. Mariborski kongres družinske medicine: zbornik. Maribor, 26.-27. november 2010. Ljubljana: Zavod za razvoj družinske medicine/ Združenje zdravnikov družinske medicine SZD, pp. 63–7.

Ramšak-Pajk, J., 2006. Dokumentacija v zdravstveni negi: pregled literature. Obzornik Zdravstvene nege, 40, pp. 137–42.

Rootmensen, G., van Keimpema, A., Jansen, H,. & de Haan, R., 2010. Predictors of incorrect inhalation technique in patients with asthma or COPD: a study using a validated videotaped scoring method. Journal of Aerosol Medicine and Pulmonary Drug Delivery, 23 (5), pp. 323–8.

Škrgat Kristan, S., Šifrer, F., Kopčavar Guček, N., Osolnik, K., Eržen, R., Fležar, M., Petek, D., Šorli, ml., J., Tomič, V., Mušič, E., Beovič, B., Šuškovič, S. & Košnik, M., 2009. Stališče do obravnave akutnega poslabšanja kronične obstruktivne pljučne bolezni (apKOPB). Zdravniški Vestnik, 78, pp. 19–32.

Tang, C.Y., Taylor, N.F., Mcdonald, C.F. & Blackstock, F.C., 2014. Level of adherence to the GOLD strategy document for management of patients admitted to hospital with an acute exacerbation of COPD. Respirology, 19 (8), pp. 1191-7.

Tower, M., Chaboyer, W., Green, Q., Dyer, K. & Wallis, M., 2012. Registered nurses' decision-making regarding documentation in patients' progress notes. Journal of Clinical Nursing, 21 (19-20), pp. 2917–29.

Vestbo, J., Hurd, S.S., Agusti, A.G., Jones, P.W., Vogelmeier, C., Anzueto, A., Barnes, P.J., Fabbri, L.M., Martinez, F.J., Nishimura, M., Stockley, R.A., Sin, D.D. & Rodriguez-Roisin, R., 2013. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. GOLD executive summary. American Journal of Respiratory and Critical Care Medicine, 187 (4), pp. 347–65.

Vestbo, J. & Lange, P., 2015. Natural history of COPD: Focusing on change in FEV1. Respirology, doi: 10.1111/resp.12589. [Epub ahead of print]

World Health Organization, 2007. The International Network of Health Promoting Hospitals and Health Services: Integrating health promotion into hospitals and health services. Concept, framework and organization. Copenhagen: World Health Organization, Regional Office for Europe.

World Health Organization, 2017. Available at: http://www.who.int/mediacentre/factsheets/fs310/en [20. 4. 2017].

World Medical Association, 2013. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. Journal of the American Medical Association, 310(20), pp. 2191–2194. Available at: http://www.wma.net/en/20activities/10ethics/10helsinki/ DoH-Oct2013-JAMA.pdf [3. 1. 2017]