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NICE case studies

Those who have been involved in the nice work programme have described it as 'a rewarding and informative experience', and felt it made a difference to their nursing practice. some examples of case studies are detailed below., fayona bareham.

It was an unexpected pleasure to attend the NICE 2019 Conference in Manchester recently. My place at the conference was supported by the Royal College of Nursing (RCN) and I would like to thank them for offering me this opportunity.

I became interested many years ago in how we as a profession can contribute to the development of guidance and policies. This led to me having the opportunity to review draft documents relevant to my skills and expertise in both Chronic Kidney Disease and Heart Failure via the RCN who act as a consultee/stakeholder for the NICE work programmes. 

The RCN encourages members with experience in the topic being addressed to review draft documents, and submit evidence if available. This can be a really positive experience contributing towards professional development, supporting revalidation, and enabling networking with a shared aim of leading improvements in patient care. Contributing in this way enables us as front line nurses to have an opportunity to influence guidance at a national level, and use our real life experience to shape future policies that we can then confidently apply in practice.

The conference exceeded all my expectations! If I’m honest I was slightly anxious about attending this conference - I felt that maybe I would be uncomfortable with the debates between the various organisations. However I found the speakers informative, the varied opinions and experiences interesting, and the overall atmosphere conducive to open discussion. Added to this was a strong representation of patients experience via patient stories and via the inclusion of patient advocates.  It was also interesting to hear how evidence is gathered and how guidance developed. 

This was of particular interest to me having recently completed a nursing research project looking at how  Advanced Nurse Practitioners working with individuals with heart failure enquire, or not, about their patients mental health. This 3 phase institutional ethnographic study showed that one of the most important facilitators to enquiring about mental health was validation of our practice and shared experience and support from colleagues. This enabled us as a varied community team, often working in isolation, to better translate the relevant NICE guidance into practice.

It’s difficult to highlight only a few points from the wealth of information on the day, but my take home messages would be:

• A quote from Dr Phil Hammond that was referred to also by other presenters as so relevant to the Public Health messages that were incorporated in many of the talks; "Why pull people out of the river of disease when you can wander upstream and stop them falling/jumping in!”
• Multimorbidity was a constant theme in common in several of the presentations. Emily Lan (Lay member) gave a description of her experiences as a patient with complex needs, and an impassioned plea for patients to be treated as a whole person. Dr Paul Chrisp (NICE) discussed how using guidelines for individual conditions without considering the patient as a whole has the potential to lead to serious drug interactions. Discussion followed around the development of Guidelines considering Multimorbidity, and this is currently being considered.
• The guidelines can only ever be as good as the information available to the people writing them. We as nurses may well have perspectives based on experiences unique to our roles, and therefore if we want the guidelines to work for us we can get involved and share our experiences. This will help ensure the guidelines reflect both patients’ needs and our ability to translate the guidelines into practice.

Norman Young

“I work as a lecturer practitioner in mental health nursing at Cardiff University and Cardiff and Vale NHS Trust. Having worked in acute psychiatry and in the community, I specialised in cognitive behaviour therapy prior to being employed by Cardiff University.

As [a] member of the Mental Health Forum in the RCN I was asked to provide comments on the NICE technological appraisal for Computerised Cognitive Behavioural Therapy for Anxiety and Depression. This work was challenging not only for its technical content but also in ensuring that the role of nurses is properly reviewed. This work provided me with an insight into NICE work programmes and the stakeholder process. It complemented a number of other technological appraisals and clinical guidelines, and provided the basis for my involvement in implementation of NICE guidance.

This case study illustrates how the work of NICE has been channelled through my clinical academic role and resulted in real improvements in health care delivery. In order to adequately implement clinical guidelines published by NICE we needed the right number of people, doing the right thing at the right time. The publication of the NICE guidance on Core Interventions for Schizophrenia in 2002 highlighted the need for local improvements in service delivery and education. A work plan was developed which included the development of two degree programmes aimed at raising the number of mental health practitioners capable of delivering NICE guidance.

While aware that training alone is insufficient for successful implementation, the work plan therefore included the development of effective leaders, service redesign in inpatient mental health, and the development of local clinical governance groups to steer developments and monitor progress.

This work has begun to embed the NICE guidance in the routine work. In 2005 a multi-agency project to develop a clinical pathway for those who experience psychosis (schizophrenia and manic depression) was initiated. With increasing numbers of people in place to deliver the interventions outlined in the NICE guidance we are now beginning to have the right people in the right place at the right time. Future work will focus on compliance and the variance associated with the integrated care pathway.”

Jane Houghton

“I work as a Nurse Consultant, Paediatric Ambulatory Care at the Lancashire Teaching Hospital NHS Foundation Trust. In 2002, I worked on behalf of the RCN as a guideline development group member for the NICE guideline: Type 1 Diabetes in Children, Young People and Adults. I was lucky enough to be one of the two nurses asked to represent the RCN from the children and young people perspective of this guideline. This was developed by the National Collaborating Centre (NCC) for Women’s and Children’s Health, where meetings were held every couple of months.

The group was multidisciplinary, including two diabetes charities and NICE staff. The scope for the guideline shaped guideline development through to recommendations for clinical practice. NICE guidelines are not about service delivery models but recommend appropriate treatment and care of people with specific diseases and conditions.

Guideline development included finalising the scope; formulating the care pathway and guideline questions; breaking the questions down; systematically searching for evidence; developing recommendations for clinical practice. Most of the researching and writing was undertaken by the NCC. The document was made available for stakeholder comments at several stages. Feedback provided was addressed. This work took two years, with the two guideline subgroups meeting just once.

Every meeting was hard work, with lots of reading prior to the meeting. The meetings however were always really enjoyable and members of the group were treated as equals, with respect for each discipline. In October 2003, as a Territorial Army nurse, I was mobilised and sent to Iraq. Whilst there, NICE continued to send me all the papers for the meetings, and passed on my comments. This was so important to me to feel part of the outside world. I returned home in time for the launch of the final document in June 2004, at the Royal College of Paediatrics and Child Health. Press was invited and with the other nurse I gave interviews regarding the content of the guideline. We felt like celebrities, having our photos published in the Nursing Standard. I have since written articles about the guideline for several nursing journals, as well as presented at several conferences.

NICE guidance in this area is in widespread use, with some of the recommendations changing practice. It has been very rewarding to see the guidelines implemented across the country. NICE was certainly NICE by name and nature!"

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About the Network

The QNI Community Nursing Senior Leaders network is a digital network for nurses with executive responsibility for the delivery of community nursing services within provider organisations in England, Wales and Northern Ireland.

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Home / Explore QNI / Community Nursing Innovation Programme / Case studies

Community Nursing Innovation Programme

Nurse led projects

Since 1990 the QNI has funded projects across the whole range of community nursing specialisms.

Case studies of nurse-led projects in the community

These projects could not be delivered without the funding that we receive from our partner organisations, including the Burdett Trust for Nursing.

Play Safe, Stay Safe

This project sought to encourage young men at the University of Huddersfield to access screening for sexually transmitted infections in a discreet way by providing self-screening STI packs available to pick up from various sites around the campus.

Relationships in Dementia

A new diagnosis of dementia can put a huge strain on any relationship. This case study describes a therapeutic support group for couples, where one of them has a new diagnosis of dementia.

Practice Development in Community Palliative Care

The key goal of palliative care is the achievement of best quality of life for patients and their families.

English for Health

This project sought to improve the health care of non-English speaking patients, and reduce inequality of access to health care within South Warwickshire. It taught patients health-related English to reduce reliance on translation services.

Mental Health of Older Men

The aim of the project was to improve the physical and mental well being of older men living in Essex by raising awareness of specific health issues, reducing isolation and promoting social inclusion.

Working Together for Health

The aim of the project was to improve the dental health, diet and physical activity of children with Autistic Spectrum Disorder (ASD) within a Primary School for children with special needs in Manchester.

Improving leg ulcer care

Venous leg ulcers affect many people, are slow to heal and frequently reoccur, taking time and resources to treat. This project aimed to improve care for these patients through a new care pathway.

Rural Hearts

This project aimed to deliver a programme of cardiac rehabilitation to patients with heart disease living in rural areas, who cannot attend hospital-based programmes.

Patient Visit Scheduling Tool

A project improved the experience of housebound patients through a new IT patient allocation system. The improved reliability of timed visits by District Nurses and has been widely adopted elsewhere.

Venous Access Device

Central Venous Access Devices deliver chemotherapy for patients at home, reducing the need to attend hospital. This project developed such a service in the community for people living in Belfast.

Water for Wellbeing project

There are serious adverse affects resulting from dehydration and many older people do not drink enough water. This project aimed to increase fluid intake by older people to benefit their health and wellbeing.

Text UR School Nurse

A Smartphone application gives young people access to key health information 24 hours a day. It engages them and encourages them to consider and change behaviour with regard to their health.

Enteral to Oral

Enteral feeding or tube feeding is often necessary to ensure adequate nutrition in sick infants and children. Weaning a child off enteral feeding can be difficult and this project sought to address the challenges.

Palliative Wellbeing in Powys

A community nurse programme to develop effective and holistic support for people who have received a terminal diagnosis, to help them and their families manage their physical, mental and emotional wellbeing.

Managing Type 1 Diabetes

Children receive dedicated support for long term conditions such as diabetes from a multi-disciplinary team. There are risks associated with the transition to adult services, due to a whole range of factors.

Hepatitis B Community Clinic

The aim of the project was to develop a specialist, nurse-led GP practice based viral Hepatitis service within Lambeth and Southwark.

Health Champions for the Homeless

The use of ‘health champions’ has proven to have a significant impact on fellow users’ attitudes and knowledge about health, accepting of lifestyle advice and access to medical care, especially in primary care.

Find out about how you can get funding for your project ideas.

About the Fund for Innovation and Leadership programme.

Find out more about alternative sources of funding.

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A 26-year-old female arrives with a companion to an urgent care at 0845 by personal vehicle for treatment of suspected foot infection. The patient’s companion (a female roommate) reports to the triage nurse that the patient cut her foot while wading in the ocean over the weekend. They did not initially notice the cut but discovered it while removing tar from the bottom of the right foot. Approximately 24 hours later, her foot became too painful for ambulation, and a “thick, yellowish” discharge began to drain from the cut. Vitals upon arrival at urgent care showed a temperature of 101.5F, heart rate of 130, respiratory rate of 24, and blood pressure of 86/40. Her pain was 9/10 in her right foot and described as throbbing. During a HTT assessment by the PA, the patient is reported to be arousable to voice, oriented to person and place only, and complaining of nausea. The patient reports she took Tylenol that morning to relieve pain and fever. Her skin is pale, diaphoretic, and hot.

The urgent care calls 911, and medics are dispatched to the center for transfer to the local hospital to treat the patient for suspected sepsis. Upon arrival, medics find the patient is still tachycardic, and that her blood pressure has dropped to 80/40. Her respiratory rate has increased to 30. During transport, medics insert a 20 gauge peripheral IVs in the patient’s left antecubital. They infuse a fluid bolus of 500 mL of normal saline to manage her patient’s hypotension, and administer oxygen by simple mask at 4L/min. During the primary assessment, the patient’s right foot reveals a two-inch laceration with no active bleeding that is erythematous, edematous (non-pitting), and radiating heat. Edema is covering the entire bottom of the right foot and extends to the patient’s ankle.

The patient arrives to the emergency room within 15 minutes and is admitted for treatment at 1000. On the unit, Code Sepsis is called, and the agency’s sepsis protocol based on the Surviving Sepsis campaign is implemented. The patient’s vitals are now a temperature of 102F, heart rate of 140, respiratory rate of 34, and blood pressure of 96/42. Lactate levels are immediately measured. A second 20 gauge peripheral IV is inserted into the right antecubital, blood cultures are drawn, and a swab sample is taken of the cut and submitted to the laboratory for a culture and sensitivity test. Broad spectrum antibiotic ceftriaxone (Rocephin) is administered, and patient is given Ibuprofen to manage her fever. The patient is diagnosed with septic shock, and because she is still hypotensive, 30mL/kg of normal saline is infused. The patient’s lactate levels come back as 2.4 mmol/L. Norepinephrine (Levophed) is also hung, and the patient is further monitored. With careful titration and vital monitoring, the use of vasopressors restores the patient’s blood pressure to 101/52. Although fluid resuscitation helps to bring the patient’s heart rate down to 104, Nicardipine (Cardene) was ordered in anticipation of further needs to manage tachycardia. The patient is transferred to the ICU at 1300 for further monitoring and management of her hemodynamic status.

In the ICU, the patient’s vitals stabilize. Her tachypneic state reduces, and respiratory rate is now 18. She no longer requires oxygen supplementation. Her pain is being managed with IV morphine and she rates the pain in her as 3/10. Her IV pump is running 125 mL an hour of normal saline along with piggybacked ceftriaxone (Rocephin), and labs return a lactate level of 1.5 mmol/L. The patient’s roommate arrives. She is tearful and explains to the ICU nurse that she wanted to tell the patient’s parents what happened, but the patient refused. The ICU nurse calls for the case manager and a social service consult to inquire further. The patient’s roommate explains to the interdisciplinary team that the patient does not have insurance because she is 26 and has been removed from her parents’ medical plan. The parents are also currently engaged in a divorce, do not speak to each other, and use their daughter to communicate. The patient is aware of their financial situation and her lack of medical coverage and does not want to worry her parents in spite of her critical medical state.

• What are the priority nursing interventions for this patient in the ICU setting?
• What signs and symptoms in this patient would indicate the need for mechanical ventilation?
• What is the nurse’s role in addressing the patient’s financial concerns?

References:

Gordon, A.C., Mason, A.J., Thirunavukkarasu, N., et al. (2016). Effect of early vasopressin vs norepinephrine on kidney failure in patient with septic shock: The VANISH randomized clinical trial. JAMA, 316 (5), 509–518. doi:10.1001/jama.2016.10485

Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth’s textbook of medical-surgical nursing. Philadelphia: Lippincott Williams & Wilkins. PulmCCM. (2019, January 14). From the Surviving Sepsis Guidelines: Criteria for diagnosis of  sepsis. Retrieved from https://pulmccm.org/review-articles/surviving-sepsis-guidelines-criteria-diagnosis-sepsis/

Schmidt, G.A., & Mandel, J. (2019, March). Evaluation and management of suspected sepsis  and septic shock in adults. Retrieved from https://www.uptodate.com/contents/evaluation-and-management-of-suspected-sepsis-and-septic-shock-in-adults?search=sepsis treatmentadult&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H465649907

Society of Critical Care Medicine. (2019). Hour-1 bundle: Initial resuscitation for sepsis and  septic shock. Retrieved from http://www.survivingsepsis.org/SiteCollectionDocuments/Surviving-Sepsis-Campaign-Hour-1-Bundle.pdf

Zhang, M., Zheng, Z., & Ma, Y. (2014). Albumin versus other fluids for fluid resuscitation in patients with sepsis: A meta-analysis. PloS one , 9 (12), e114666.

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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STEVE FORD, EDITOR

• You are here: COPD

Diagnosis and management of COPD: a case study

04 May, 2020

This case study explains the symptoms, causes, pathophysiology, diagnosis and management of chronic obstructive pulmonary disease

This article uses a case study to discuss the symptoms, causes and management of chronic obstructive pulmonary disease, describing the patient’s associated pathophysiology. Diagnosis involves spirometry testing to measure the volume of air that can be exhaled; it is often performed after administering a short-acting beta-agonist. Management of chronic obstructive pulmonary disease involves lifestyle interventions – vaccinations, smoking cessation and pulmonary rehabilitation – pharmacological interventions and self-management.

Citation: Price D, Williams N (2020) Diagnosis and management of COPD: a case study. Nursing Times [online]; 116: 6, 36-38.

Authors: Debbie Price is lead practice nurse, Llandrindod Wells Medical Practice; Nikki Williams is associate professor of respiratory and sleep physiology, Swansea University.

• This article has been double-blind peer reviewed
• Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)

Introduction

The term chronic obstructive pulmonary disease (COPD) is used to describe a number of conditions, including chronic bronchitis and emphysema. Although common, preventable and treatable, COPD was projected to become the third leading cause of death globally by 2020 (Lozano et al, 2012). In the UK in 2012, approximately 30,000 people died of COPD – 5.3% of the total number of deaths. By 2016, information published by the World Health Organization indicated that Lozano et al (2012)’s projection had already come true.

People with COPD experience persistent respiratory symptoms and airflow limitation that can be due to airway or alveolar abnormalities, caused by significant exposure to noxious particles or gases, commonly from tobacco smoking. The projected level of disease burden poses a major public-health challenge and primary care nurses can be pivotal in the early identification, assessment and management of COPD (Hooper et al, 2012).

Grace Parker (the patient’s name has been changed) attends a nurse-led COPD clinic for routine reviews. A widowed, 60-year-old, retired post office clerk, her main complaint is breathlessness after moderate exertion. She scored 3 on the modified Medical Research Council (mMRC) scale (Fletcher et al, 1959), indicating she is unable to walk more than 100 yards without stopping due to breathlessness. Ms Parker also has a cough that produces yellow sputum (particularly in the mornings) and an intermittent wheeze. Her symptoms have worsened over the last six months. She feels anxious leaving the house alone because of her breathlessness and reduced exercise tolerance, and scored 26 on the COPD Assessment Test (CAT, catestonline.org), indicating a high level of impact.

Ms Parker smokes 10 cigarettes a day and has a pack-year score of 29. She has not experienced any haemoptysis (coughing up blood) or chest pain, and her weight is stable; a body mass index of 40kg/m 2 means she is classified as obese. She has had three exacerbations of COPD in the previous 12 months, each managed in the community with antibiotics, steroids and salbutamol.

Ms Parker was diagnosed with COPD five years ago. Using Epstein et al’s (2008) guidelines, a nurse took a history from her, which provided 80% of the information needed for a COPD diagnosis; it was then confirmed following spirometry testing as per National Institute for Health and Care Excellence (2018) guidance.

The nurse used the Calgary-Cambridge consultation model, as it combines the pathological description of COPD with the patient’s subjective experience of the illness (Silverman et al, 2013). Effective communication skills are essential in building a trusting therapeutic relationship, as the quality of the relationship between Ms Parker and the nurse will have a direct impact on the effectiveness of clinical outcomes (Fawcett and Rhynas, 2012).

In a national clinical audit report, Baxter et al (2016) identified inaccurate history taking and inadequately performed spirometry as important factors in the inaccurate diagnosis of COPD on general practice COPD registers; only 52.1% of patients included in the report had received quality-assured spirometry.

Pathophysiology of COPD

Knowing the pathophysiology of COPD allowed the nurse to recognise and understand the physical symptoms and provide effective care (Mitchell, 2015). Continued exposure to tobacco smoke is the likely cause of the damage to Ms Parker’s small airways, causing her cough and increased sputum production. She could also have chronic inflammation, resulting in airway smooth-muscle contraction, sluggish ciliary movement, hypertrophy and hyperplasia of mucus-secreting goblet cells, as well as release of inflammatory mediators (Mitchell, 2015).

Ms Parker may also have emphysema, which leads to damaged parenchyma (alveoli and structures involved in gas exchange) and loss of alveolar attachments (elastic connective fibres). This causes gas trapping, dynamic hyperinflation, decreased expiratory flow rates and airway collapse, particularly during expiration (Kaufman, 2013). Ms Parker also displayed pursed-lip breathing; this is a technique used to lengthen the expiratory time and improve gaseous exchange, and is a sign of dynamic hyperinflation (Douglas et al, 2013).

In a healthy lung, the destruction and repair of alveolar tissue depends on proteases and antiproteases, mainly released by neutrophils and macrophages. Inhaling cigarette smoke disrupts the usually delicately balanced activity of these enzymes, resulting in the parenchymal damage and small airways (with a lumen of <2mm in diameter) airways disease that is characteristic of emphysema. The severity of parenchymal damage or small airways disease varies, with no pattern related to disease progression (Global Initiative for Chronic Obstructive Lung Disease, 2018).

Ms Parker also had a wheeze, heard through a stethoscope as a continuous whistling sound, which arises from turbulent airflow through constricted airway smooth muscle, a process noted by Mitchell (2015). The wheeze, her 29 pack-year score, exertional breathlessness, cough, sputum production and tiredness, and the findings from her physical examination, were consistent with a diagnosis of COPD (GOLD, 2018; NICE, 2018).

Spirometry is a tool used to identify airflow obstruction but does not identify the cause. Commonly measured parameters are:

• Forced expiratory volume – the volume of air that can be exhaled – in one second (FEV1), starting from a maximal inspiration (in litres);
• Forced vital capacity (FVC) – the total volume of air that can be forcibly exhaled – at timed intervals, starting from a maximal inspiration (in litres).

Calculating the FEV1 as a percentage of the FVC gives the forced expiratory ratio (FEV1/FVC). This provides an index of airflow obstruction; the lower the ratio, the greater the degree of obstruction. In the absence of respiratory disease, FEV1 should be ≥70% of FVC. An FEV1/FVC of <70% is commonly used to denote airflow obstruction (Moore, 2012).

As they are time dependent, FEV1 and FEV1/FVC are reduced in diseases that cause airways to narrow and expiration to slow. FVC, however, is not time dependent: with enough expiratory time, a person can usually exhale to their full FVC. Lung function parameters vary depending on age, height, gender and ethnicity, so the degree of FEV1 and FVC impairment is calculated by comparing a person’s recorded values with predicted values. A recorded value of >80% of the predicted value has been considered ‘normal’ for spirometry parameters but the lower limit of normal – equal to the fifth percentile of a healthy, non-smoking population – based on more robust statistical models is increasingly being used (Cooper et al, 2017).

A reversibility test involves performing spirometry before and after administering a short-acting beta-agonist (SABA) such as salbutamol; the test is used to distinguish between reversible and fixed airflow obstruction. For symptomatic asthma, airflow obstruction due to airway smooth-muscle contraction is reversible: administering a SABA results in smooth-muscle relaxation and improved airflow (Lumb, 2016). However, COPD is associated with fixed airflow obstruction, resulting from neutrophil-driven inflammatory changes, excess mucus secretion and disrupted alveolar attachments, as opposed to airway smooth-muscle contraction.

Administering a SABA for COPD does not usually produce bronchodilation to the extent seen in someone with asthma: a person with asthma may demonstrate significant improvement in FEV1 (of >400ml) after having a SABA, but this may not change in someone with COPD (NICE, 2018). However, a negative response does not rule out therapeutic benefit from long-term SABA use (Marín et al, 2014).

NICE (2018) and GOLD (2018) guidelines advocate performing spirometry after administering a bronchodilator to diagnose COPD. Both suggest a FEV1/FVC of <70% in a person with respiratory symptoms supports a diagnosis of COPD, and both grade the severity of the condition using the predicted FEV1. Ms Parker’s spirometry results showed an FEV1/FVC of 56% and a predicted FEV1 of 57%, with no significant improvement in these values with a reversibility test.

GOLD (2018) guidance is widely accepted and used internationally. However, it was developed by medical practitioners with a medicalised approach, so there is potential for a bias towards pharmacological management of COPD. NICE (2018) guidance may be more useful for practice nurses, as it was developed by a multidisciplinary team using evidence from systematic reviews or meta-analyses of randomised controlled trials, providing a holistic approach. NICE guidance may be outdated on publication, but regular reviews are performed and published online.

NHS England (2016) holds a national register of all health professionals certified in spirometry. It was set up to raise spirometry standards across the country.

Assessment and management

The goals of assessing and managing Ms Parker’s COPD are to:

• Review and determine the level of airflow obstruction;
• Assess the disease’s impact on her life;
• Risk assess future disease progression and exacerbations;
• Recommend pharmacological and therapeutic management.

GOLD’s (2018) ABCD assessment tool (Fig 1) grades COPD severity using spirometry results, number of exacerbations, CAT score and mMRC score, and can be used to support evidence-based pharmacological management of COPD.

When Ms Parker was diagnosed, her predicted FEV1 of 57% categorised her as GOLD grade 2, and her mMRC score, CAT score and exacerbation history placed her in group D. The mMRC scale only measures breathlessness, but the CAT also assesses the impact COPD has on her life, meaning consecutive CAT scores can be compared, providing valuable information for follow-up and management (Zhao, et al, 2014).

After assessing the level of disease burden,  Ms Parker was then provided with education for self-management and lifestyle interventions.

Lifestyle interventions

Smoking cessation.

Cessation of smoking alongside support and pharmacotherapy is the second-most cost-effective intervention for COPD, when compared with most other pharmacological interventions (BTS and PCRS UK, 2012). Smoking cessation:

• Slows the progression of COPD;
• Improves lung function;
• Improves survival rates;
• Reduces the risk of lung cancer;
• Reduces the risk of coronary heart disease risk (Qureshi et al, 2014).

Ms Parker accepted a referral to an All Wales Smoking Cessation Service adviser based at her GP surgery. The adviser used the internationally accepted ‘five As’ approach:

• Ask – record the number of cigarettes the individual smokes per day or week, and the year they started smoking;
• Advise – urge them to quit. Advice should be clear and personalised;
• Assess – determine their willingness and confidence to attempt to quit. Note the state of change;
• Assist – help them to quit. Provide behavioural support and recommend or prescribe pharmacological aids. If they are not ready to quit, promote motivation for a future attempt;
• Arrange – book a follow-up appointment within one week or, if appropriate, refer them to a specialist cessation service for intensive support. Document the intervention.

NICE (2013) guidance recommends that this be used at every opportunity. Stead et al (2016) suggested that a combination of counselling and pharmacotherapy have proven to be the most effective strategy.

Pulmonary rehabilitation

Ms Parker’s positive response to smoking cessation provided an ideal opportunity to offer her pulmonary rehabilitation (PR)  – as indicated by Johnson et al (2014), changing one behaviour significantly increases a person’s chance of changing another.

PR – a supervised programme including exercise training, health education and breathing techniques – is an evidence-based, comprehensive, multidisciplinary intervention that:

• Improves exercise tolerance;
• Reduces dyspnoea;
• Promotes weight loss (Bolton et al, 2013).

These improvements often lead to an improved quality of life (Sciriha et al, 2015).

Most relevant for Ms Parker, PR has been shown to reduce anxiety and depression, which are linked to an increased risk of exacerbations and poorer health status (Miller and Davenport, 2015). People most at risk of future exacerbations are those who already experience them (Agusti et al, 2010), as in Ms Parker’s case. Patients who have frequent exacerbations have a lower quality of life, quicker progression of disease, reduced mobility and more-rapid decline in lung function than those who do not (Donaldson et al, 2002).

“COPD is a major public-health challenge; nurses can be pivotal in early identification, assessment and management”

Pharmacological interventions

Ms Parker has been prescribed inhaled salbutamol as required; this is a SABA that mediates the increase of cyclic adenosine monophosphate in airway smooth-muscle cells, leading to muscle relaxation and bronchodilation. SABAs facilitate lung emptying by dilatating the small airways, reversing dynamic hyperinflation of the lungs (Thomas et al, 2013). Ms Parker also uses a long-acting muscarinic antagonist (LAMA) inhaler, which works by blocking the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors in airway smooth muscle; release of acetylcholine by the parasympathetic nerves in the airways results in increased airway tone with reduced diameter.

At a routine review, Ms Parker admitted to only using the SABA and LAMA inhalers, despite also being prescribed a combined inhaled corticosteroid and long-acting beta 2 -agonist (ICS/LABA) inhaler. She was unaware that ICS/LABA inhalers are preferred over SABA inhalers, as they:

• Last for 12 hours;
• Improve the symptoms of breathlessness;
• Increase exercise tolerance;
• Can reduce the frequency of exacerbations (Agusti et al, 2010).

However, moderate-quality evidence shows that ICS/LABA combinations, particularly fluticasone, cause an increased risk of pneumonia (Suissa et al, 2013; Nannini et al, 2007). Inhaler choice should, therefore, be individualised, based on symptoms, delivery technique, patient education and compliance.

It is essential to teach and assess inhaler technique at every review (NICE, 2011). Ms Parker uses both a metered-dose inhaler and a dry-powder inhaler; an in-check device is used to assess her inspiratory effort, as different inhaler types require different inhalation speeds. Braido et al (2016) estimated that 50% of patients have poor inhaler technique, which may be due to health professionals lacking the confidence and capability to teach and assess their use.

Patients may also not have the dexterity, capacity to learn or vision required to use the inhaler. Online resources are available from, for example, RightBreathe (rightbreathe.com), British Lung Foundation (blf.org.uk). Ms Parker’s adherence could be improved through once-daily inhalers, as indicated by results from a study by Lipson et al (2017). Any change in her inhaler would be monitored as per local policy.

Vaccinations

Ms Parker keeps up to date with her seasonal influenza and pneumococcus vaccinations. This is in line with the low-cost, highest-benefit strategy identified by the British Thoracic Society and Primary Care Respiratory Society UK’s (2012) study, which was conducted to inform interventions for patients with COPD and their relative quality-adjusted life years. Influenza vaccinations have been shown to decrease the risk of lower respiratory tract infections and concurrent COPD exacerbations (Walters et al, 2017; Department of Health, 2011; Poole et al, 2006).

Self-management

Ms Parker was given a self-management plan that included:

• Information on how to monitor her symptoms;
• A rescue pack of antibiotics, steroids and salbutamol;
• A traffic-light system demonstrating when, and how, to commence treatment or seek medical help.

Self-management plans and rescue packs have been shown to reduce symptoms of an exacerbation (Baxter et al, 2016), allowing patients to be cared for in the community rather than in a hospital setting and increasing patient satisfaction (Fletcher and Dahl, 2013).

Improving Ms Parker’s adherence to once-daily inhalers and supporting her to self-manage and make the necessary lifestyle changes, should improve her symptoms and result in fewer exacerbations.

The earlier a diagnosis of COPD is made, the greater the chances of reducing lung damage through interventions such as smoking cessation, lifestyle modifications and treatment, if required (Price et al, 2011).

• Chronic obstructive pulmonary disease is a progressive respiratory condition, projected to become the third leading cause of death globally
• Diagnosis involves taking a patient history and performing spirometry testing
• Spirometry identifies airflow obstruction by measuring the volume of air that can be exhaled
• Chronic obstructive pulmonary disease is managed with lifestyle and pharmacological interventions, as well as self-management

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Delve into the intricacies of a nursing case study, a critical component in nursing education and practice. This comprehensive guide will establish a robust understanding of the construction, relevance, and application of these integral studies. You'll explore various formats, ethical implications, and practical examples, ultimately honing your skills in creating effective nursing case studies. With an in-depth analysis and step-by-step guidance, this guide is crucial for aspiring or seasoned nursing professionals looking to enhance their case study proficiency.

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Understanding the Concept of a Nursing Case Study

Entering the field of nursing often requires more than simple rote learning. It demands an in-depth understanding of specific patient conditions, collaborative care planning, and the application of theoretical knowledge in practical scenarios. This is where a nursing case study plays a key role.

A nursing case study is a comprehensive examination of a patient's status, which comprises the gathering, assessment, and interpretation of data through various medical examinations and tests. This process allows healthcare professionals to make better-informed decisions about a patient's care plan and overall health management.

What is a Nursing Case Study: An Introduction

A Nursing Case Study is an in-depth examination of a patient case, wherein the nurse documents detailed information about the patient—everything from their initial history, diagnosis, to treatment—whilst also noting observations and reflecting on their nursing care.

A nursing case study typically includes sections for patient history, diagnosis, nursing assessment, treatment, and results. You will:

• Start by documenting a detailed patient history including previous medical conditions and lifestyle.
• Then, you'll progress to the diagnosis of the patient's condition.
• Next, perform a nursing assessment to identify potential health risks or complications.
• Formulate a treatment plan based on the assessment.
• And finally, evaluate the results of the treatment plan and adjust as necessary.

These comprehensive evaluations are critical in the field of nursing as they not only allow for appropriate patient care but also help guide future medical recommendations.

For example, consider a patient diagnosed with type 2 diabetes who complains of unexpected weight loss. A comprehensive nursing case study would involve recording the patient's current symptoms, medical history, conducting a nursing assessment to identify potential complications, and formulating a treatment plan. The results of this treatment would be regularly evaluated and adjusted to optimise the patient's health.

Importance and Relevance of a Nursing Case Study in Clinical Placement

A nursing case study plays an indispensable role in clinical placement . As you navigate your clinical experience :/p>

• You can use case studies as a reference tool in diagnosing, planning, implementing and evaluating patient care .
• Through case studies, you can also enhance your critical thinking and problem-solving skills.

Clinical placement refers to the practice-based learning experience that allows nursing students to apply their theoretical knowledge in a real-world clinic or hospital setting.

Such hands-on experience is essential to developing a solid understanding and mastery in nursing. A thorough nursing case study stands as a practical resource, providing valuable insights into complex patient conditions and providing a framework for delivering effective patient care. Furthermore, it also enables better comprehension of theoretical practice, thus bridging the gap between theory and application in nursing.

Exploring the Format of a Case Study in Nursing

It is crucial to understand the layout of a nursing case study. Having a solid grasp of the format will enable you to document all essential pieces of information about your patient care efficiently and thoroughly. Furthermore, clear structuring strongly supports effective communication within the healthcare team .

Remember, just like other academic papers, a nursing case study generally follows a logical flow that reflects the nursing process . This process includes five steps: Assessment, Diagnosis, Planning, Implementation and Evaluation; often abbreviated as ADPIE.

How to Write a Nursing Case Study: Step by Step Guide

When writing a nursing case study, it's vital to maintain a clear, structured and detail-oriented approach. Here, you will learn a standard step-by-step guide to creating your case study.

• Review the Patient History : Start by gathering all relevant details about the patient's medical history. Include specifics like past medical conditions, medication use, lifestyle factors and family history of diseases.
• Document Recent Health Assessments : Mention any recent diagnostic tests and their results, physical examination findings, and present complaints or conditions if any.
• Analyze Clinical Data : Analyze the data from the assessments and tests to identify any pertinent patterns or connections.
• Formulate Nursing Diagnoses : Based on your analysis, formulate nursing diagnoses . A nursing diagnosis can be described as a clinical judgement concerning a human response to health conditions.
• Develop a Comprehensive Care Plan : After diagnosis, establish a comprehensive care plan detailing the intended therapeutic interventions and expected outcomes. Remember, it's crucial to form SMART (Specific, Measurable, Achievable, Relevant, Time-bound) outcomes.
• Evaluate Progress : Lastly, evaluate the patient's progress towards the desired outcome and note any necessary changes to the care plan.

Please, keep in mind that the case study should follow a narrative approach, ensuring the information flows logically while maintaining patient confidentiality at all times.

An example could be a nursing case study for a patient with pneumonia . First, the patient's history is gathered, noting previous respiratory issues or any risk factors like smoking or occupational exposure. Next, the current clinical data would be documented, such as the results of a chest X-ray showing an infection in the lungs , together with vital signs and physical examination results. The data is then analyzed to arrive at a nursing diagnosis of impaired gas exchange related to alveolar consolidation, as evidenced by abnormal breath sounds and decreased oxygen saturation levels. The care plan would include interventions such as administering prescribed medications, oxygen therapy , and promoting good lung hygiene, with the expected outcome of improved respiratory function. Regular progress evaluations would be made, adjusting the plan as required.

Key Components of a Well-Written Nursing Case Study

The resultant quality of a case study depends on whether all key components are properly addressed. Here are some pivotal sections that should be present:

• Introduction : This provides a brief overview of the patient's demographic information and reason for admission.
• Patient History : The patient’s medical, surgical, and family history, including lifestyle factors.
• Physical Examination : Findings from the nurse's initial physical assessment of the patient, noting any abnormalities.
• Nursing Assessment : Identification of health issues or potential complications based on nursing theory.
• Nursing Diagnosis : Clinical judgement concerning a human response to health conditions.
• Nursing Interventions and Rationale : Explanation of the actions taken by the nurse to reach the planned outcomes, with a clear rationale behind each intervention.
• Expected Results and Actual Outcomes : Anticipation of results after interventions and comparison with actual outcomes. Adjustments to interventions may be made based on this comparison.

By giving due importance to each of these components, you ensure that the case study is comprehensive, accurate, and informative. This process aids in the ongoing optimisation of patient care, and shows the continual evidence-based practice in nursing.

Diving into Nursing Case Study Examples

An understanding of nursing case studies is significantly enhanced with the examination of practical examples. Analysis of these examples provides a real-life context to theories and practices, reinforcing their relevance and applicability. It is a great tool for learning by experience and expanding your knowledge in the field.

Reviewing nursing case study examples can spotlight the importance of thorough data collection, patient history compilation, diagnosis determination, and subsequent treatment provisioning. It permits you to appreciate the diversity of patient conditions, honing your skills in managing complex health situations effectively.

Nurse Practitioner Case Studies: Comprehensive Analysis

Nurse Practitioner case studies offer rich insights into the critical role nurse practitioners play within healthcare teams, particularly in primary care settings.

A Nurse Practitioner (NP) is a registered nurse with additional education and training in a particular area like family practice or paediatrics allowing them to examine, diagnose, and treat patients.

By looking into nurse practitioner case studies, you can expand your understanding of the advanced critical thinking, decision-making, and leadership skills exercised by NPs in diverse health scenarios. Here are the major steps that are typically followed during case analysis:

• First Step - Understanding the Patient's Details : The big picture of the patient's background, including their demographics, social, medical and personal history.
• Second Step - Identification of the Care Gaps : Identifying the issues in the existing care provision and areas of improvement for the Nurse Practitioner.
• Third Step - Formulation of a Healthcare Plan : The NP devises a robust patient-specific care plan detailing the required interventions.
• Fourth Step - Execution and Evaluation of the Plan : The plan is implemented, and the results are closely monitored for necessary changes.

Consider a Nurse Practitioner case study involving a 70-year-old female with a history of hypertension . The patient complaints of frequent headaches and tiredness. The NP begins by understanding the patient's overall health background, and then identifies the gaps in care—possibly inadequate control of hypertension. The NP formulates a plan that includes adjustment of antihypertensive drugs, lifestyle changes, and regular blood pressure monitoring . The execution of this plan is followed by a careful analysis of the patient's improvement in symptoms and hypertension control.

Delegation of Nursing Management Case Study: An Overview

Evaluating delegation in nursing management through case studies is an excellent way to understand its significance in nursing practice and learn the best principles for its application.

Delegation in nursing management refers to the process of assigning tasks to subordinates or team members in a way that maximises the efficiency and effectiveness of healthcare delivery.

Delegation is a crucial skill for every nurse, especially for those in leadership roles. It not only ensures smoother workflow but also empowers less experienced nurses, imparting skill development opportunities. The following points are important when analysing a delegation case study:

• Assessing the Situation : First, understand the precise patient care scenario and the workforce available.
• Identifying the Skills Required : After assessing the situation, identify the kind of skills needed for the delegated tasks.
• Assigning the Task : Delegate the task to the most competent and available person, considering their individual competencies and workload.
• Monitoring and Feedback : After delegation, it's crucial to supervise the task completion and provide constructive feedback to enhance performance in the future.

For instance, consider a case study highlighting delegation in a busy hospital setting. The nurse manager has to manage the care of 30 patients with only five nurses on duty. After assessing the situation and the individual abilities of the nurses, she assigns roles like medication administration , wound care , and patient education optimally. She then monitors the work and offers feedback after the shift, leading to efficient patient care despite the heavy workload.

Learning from these case studies equips you with efficient strategies for nursing management and ensures streamlined patient care. This knowledge acquisition is essential in modern healthcare settings to establish a patient-centred, coordinated approach.

Case Studies in Nursing Ethics

Examining case studies in nursing ethics is an invaluable way to explore the complex nature of ethical dilemmas in clinical settings. It allows you to conceptualise ethical concepts applied to patient care, while providing robust resources for learning and growth.

These case studies essentially offer an exploration into the intersection of healthcare, morality, philosophy, and social justice, which is represented in daily nursing practice.

Ethical Dilemmas in Nursing: Case Study Illustrations

An 'ethical dilemma' refers to situations where moral obligations conflict or where moral reasoning is not clear-cut. Nurses frequently encounter such dilemmas in their practice, making it crucial to understand how to approach these complex situations.

Ethical dilemma in nursing is a scenario where a decision must be made between two morally correct courses of action, but they are conflicting.

In nursing, the prime focus is always to provide the best possible care for a patient. However, ethical dilemmas arise when the right course of action is unclear, or when different beliefs and values clash. These situations can be stressful and deciding on the course of action can be challenging. Reviewing case study illustrations of ethical dilemmas can be a powerful teaching tool that facilitates a deeper understanding of these challenges.

Here are the most common ethical dilemmas that nurses face:

• Disclosure : How much information about the patient's health should be shared and with whom?
• Quality of Life : When a patient is suffering, what measures should be taken to maintain quality of life versus prolonging life itself?
• Professional Boundaries : How does a nurse maintain the right balance between being professional yet compassionate and empathetic?
• Cultural Differences : Treatment should be offered based on the patient's cultural beliefs, but what happens when these are in conflict with standard healthcare practices?
• End of Life Decisions : Addressing issues like euthanasia, Do Not Resuscitate orders and withdrawal or withholding of treatment.

It’s worth remembering that these issues often put a nurse’s professional duty against their personal beliefs, which further increases the complexity of managing them effectively.

For instance, consider a scenario where a patient’s religious beliefs prohibit blood transfusions, but they require one to survive. In carrying out the patient's wishes, the health provider might have to compromise the patient's wellbeing. Conversely, if the nurse ignores the patient's wishes to save their life, it can be considered a disregard for the patient's autonomy and beliefs. Thus, navigating this delicate balance may present an ethical dilemma.

Learning from Ethical Scenarios in Nursing Case Studies

Each ethical scenario in nursing case studies is a profound learning opportunity. Through exploring these intense and complex scenarios, you evolve as a nurse, honing your critical thinking, decision-making and reflection skills.

When analysing an ethical scenario, it's best to follow these steps:

• Identify the Dilemma : First, identify the ethical issue at hand and why it creates a dilemma.
• Understand the Context : Ascertain the involved parties, their beliefs or values, and how they relate to the situation.
• Evaluate the Options : Review the possible actions you could take, bearing in mind ethical guidelines and professional duties.
• Seek Advice : Consult with colleagues, mentors or your nursing governing body if in doubt. Asking for perspectives helps create a broader view of options.
• Make an Informed Decision : Based on all the information and advice, make a decision. Always keep the patient's best interest in focus.

Consider a case study where a patient refuses necessary treatment due to their religious beliefs. You first identify the ethical dilemma: respecting the patient's autonomous decision versus ensuring their wellbeing. The context includes the patient's health condition and their deeply-held religious belief. Possible options would be to respect the patient's choice, seek legal advice, discuss alternatives, or try to convince the patient or their family. Seeking advice from senior colleagues or the nurse manager may offer valuable insights into managing such situations. Finally, the decision should be taken considering all perspectives while maintaining the prime focus on the patient's wellbeing and rights.

With each ethical scenario analysed, you gain a deeper understanding of the ethical dimensions of nursing. This understanding fortifies your ability to provide effective, ethical patient care and to handle challenging situations in your nursing journey.

Tips and Techniques for an Effective Nursing Case Study

Nursing case studies are an integral part of nursing education and practice. They provide an in-depth insight into patient care, from diagnosis to treatment, through a practical approach. Understanding how to write them effectively is a vital skill for both nursing students and practicing nurses.

Improving Your Writing Skills for Nursing Case Studies

Improving your writing skills specifically for nursing case studies primarily means honing your ability to accurately document and articulate patient interactions, clinical symptoms, nursing interventions , and treatment results. It’s about refining your observational, analytic, and reporting skills.

Here's a list of techniques you can follow to enhance your case study writing skills :

• Understand the Format : Familiarise yourself with the structure and formatting of nursing case studies. Standard sections include patient history, diagnosis, nursing assessments, treatment, and evaluation.
• Be Clear and Precise : Use clear, precise language and mention facts accurately. Avoid unneeded jargon or long sentences.
• Consistent Clinical Terminology : Utilise the approved clinical language, acronyms, and terminology consistently for clarity and professionalism.
• Detail-Oriented Observation : Be observant about the smallest details related to a patient's symptoms, behaviours, reactions to interventions, and overall progress. Every tiny detail could be significant.
• Reflective Thinking : Develop your reflective thinking skills. Reflect on your nursing interventions: what has worked, what hasn't, and potential improvements.

Reflective thinking in nursing is a process where nurses analyse their clinical experiences to learn and improve their practices. It aids in transforming practical experiences into meaningful knowledge.

Suppose you are documenting a case study about a patient with diabetes suffering from recurring cases of hypoglycaemia. You'll need to provide a comprehensive patient history, precise details about their symptoms, and a clear description of your nursing interventions to prevent these episodes. Be sure to use consistent terminology and observe all related factors, like the patient's diet or emotional state, which could impact their sugar levels. The report should include regular evaluations of the patient's condition, and your reflections on the efficacy of your implemented care plan.

Do's and Don'ts in Writing a Nursing Case Study

To ensure you create compelling, informative, and accurate nursing case studies, here are some indispensable do's and don'ts to keep in mind:

Reflective writing in nursing case studies is a process where nurses consider their experiences, actions, feelings, and responses and analyse their impacts on patient outcomes . It includes assessing what was done well, what could be improved, and steps for future development.

If you have handled an incident of rapid patient deterioration in a clinical setting, instead of merely describing the event chronologically in the case study, engage in reflective writing. Discuss the nursing assessments undertaken, the intuitions you had, the quick decisions you made, and the outcomes you achieved. Reflect on your emotions, your learning, and the improvements you would implement in similar future scenarios.

Following these tips will, without a doubt, help you improve the quality of your nursing case studies, either for academic or professional purposes. Understanding the importance of each step, from precise patient details to reflective evaluations, is key to writing an effective nursing case study.

Nursing Case Study - Key takeaways

• A Nursing Case Study involves gathering patient history, analyzing clinical data, formulating nursing diagnoses, developing a comprehensive care plan, and evaluating progress.
• Nursing Case Study examples illuminate the process and importance of thorough data collection, patient history compilation, diagnosis determination, and subsequent treatment.
• The delegation of nursing management Case Study explores the efficient assignment of tasks within a nursing team, maximizing efficiency and effectiveness of healthcare delivery.
• Case studies in nursing ethics provide insight into ethical dilemmas in clinical settings and help to conceptualize ethical concepts applied to patient care.
• The format of a nursing case study typically includes an introduction, patient history, physical/nursing assessment, nursing diagnosis, nursing interventions and rationale, and expected/actual outcomes.

Flashcards in Nursing Case Study 30

What is a Nursing Case Study?

A nursing case study is an in-depth analysis of a patient or group of patients, involving observations, data collection, diagnosis, planning and implementing interventions, then evaluating outcomes. It incorporates a nurse's clinical reasoning in patient care.

What is the significance of case studies in Nursing education and practice?

Case studies bridge theoretical learning and actual practice, enabling the application of learned knowledge in real scenarios. They promote critical thinking, decision-making, and enhance clinical skills while providing evidence-based learning.

How does a nurse proceed with a nursing case study?

The nurse analyses patients’ health records, carries out physical assessments, interacts with patients to gain insights into their experiences, symptoms, and responses to treatment, and implements interventions while evaluating the outcomes.

What are nursing case study examples and what do they provide?

Nursing case study examples provide insights into how theoretical nursing knowledge is applied in real-world situations. They equip you with an understanding of different patient conditions and nursing responsibilities.

What does a nursing management case study involving delegation illustrate?

A nursing management case study involving delegation shows the importance of efficient task distribution, quick judgment-making in stressful situations, and careful selection of staff members for specific tasks based on their competence.

What do Nurse Practitioner case studies typically illustrate?

Nurse Practitioner case studies illustrate the comprehensive, patient-centred care provided by NPs, including initial interaction and assessment, diagnosis and treatment, and evaluating outcomes through patient responsiveness over time.

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O'Donovan K. Angiotensin receptor blockers as an alternative to angiotensin converting enzyme inhibitors. British Journal of Cardiac Nursing. 2019; 14:(6)1-12 https://doi.org/10.12968/bjca.2019.0009

Porth CM. Essentials of Pathophysiology, 4th edn. Philadelphia: Wolters Kluwer; 2015

Rae B. Obedience to collaboration: compliance, adherence and concordance. Journal of Prescribing Practice. 2021; 3:(6)235-240 https://doi.org/10.12968/jprp.2021.3.6.235

Rostoft S, van den Bos F, Pedersen R, Hamaker ME. Shared decision-making in older patients with cancer - What does the patient want?. J Geriatr Oncol. 2021; 12:(3)339-342 https://doi.org/10.1016/j.jgo.2020.08.001

Schroeder K. The 10-minute clinical assessment, 2nd edn. Oxford: Wiley Blackwell; 2017

Thomas J, Monaghan T. The Oxford handbook of clinical examination and practical skills, 2nd edn. Oxford: Oxford University Press; 2014

Vincer K, Kaufman G. Balancing shared decision-making with ethical principles in optimising medicines. Nurse Prescribing. 2017; 15:(12)594-599 https://doi.org/10.12968/npre.2017.15.12.594

Waterfield J. ACE inhibitors: use, actions and prescribing rationale. Nurse Prescribing. 2008; 6:(3)110-114 https://doi.org/10.12968/npre.2008.6.3.28858

Weiss M. Concordance, 6th edn. In: Watson J, Cogan LS Poland: Elsevier; 2019

Williams H. An update on hypertension for nurse prescribers. Nurse Prescribing. 2013; 11:(2)70-75 https://doi.org/10.12968/npre.2013.11.2.70

Adherence to long-term therapies, evidence for action.Geneva: WHO; 2003

Young K, Franklin P, Franklin P. Effective consulting and historytaking skills for prescribing practice. Br J Nurs. 2009; 18:(17)1056-1061 https://doi.org/10.12968/bjon.2009.18.17.44160

Newly diagnosed hypertension: case study

Angela Brown

Trainee Advanced Nurse Practitioner, East Belfast GP Federation, Northern Ireland

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The role of an advanced nurse practitioner encompasses the assessment, diagnosis and treatment of a range of conditions. This case study presents a patient with newly diagnosed hypertension. It demonstrates effective history taking, physical examination, differential diagnoses and the shared decision making which occurred between the patient and the professional. It is widely acknowledged that adherence to medications is poor in long-term conditions, such as hypertension, but using a concordant approach in practice can optimise patient outcomes. This case study outlines a concordant approach to consultations in clinical practice which can enhance adherence in long-term conditions.

Hypertension is a worldwide problem with substantial consequences ( Fisher and Curfman, 2018 ). It is a progressive condition ( Jamison, 2006 ) requiring lifelong management with pharmacological treatments and lifestyle adjustments. However, adopting these lifestyle changes can be notoriously difficult to implement and sustain ( Fisher and Curfman, 2018 ) and non-adherence to chronic medication regimens is extremely common ( Abegaz et al, 2017 ). This is also recognised by the National Institute for Health and Care Excellence (NICE) (2009) which estimates that between 33.3% and 50% of medications are not taken as recommended. Abegaz et al (2017) furthered this by claiming 83.7% of people with uncontrolled hypertension do not take medications as prescribed. However, leaving hypertension untreated or uncontrolled is the single largest cause of cardiovascular disease ( Fisher and Curfman, 2018 ). Therefore, better adherence to medications is associated with better outcomes ( World Health Organization, 2003 ) in terms of reducing the financial burden associated with the disease process on the health service, improving outcomes for patients ( Chakrabarti, 2014 ) and increasing job satisfaction for professionals ( McKinnon, 2013 ). Therefore, at a time when growing numbers of patients are presenting with hypertension, health professionals must adopt a concordant approach from the initial consultation to optimise adherence.

Great emphasis is placed on optimising adherence to medications ( NICE, 2009 ), but the meaning of the term ‘adherence’ is not clear and it is sometimes used interchangeably with compliance and concordance ( De Mauri et al, 2022 ), although they are not synonyms. Compliance is an outdated term alluding to paternalism, obedience and passivity from the patient ( Rae, 2021 ), whereby the patient's behaviour must conform to the health professional's recommendations. Adherence is defined as ‘the extent to which a person's behaviour, taking medication, following a diet and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider’ ( Chakrabarti, 2014 ). This term is preferred over compliance as it is less paternalistic ( Rae, 2021 ), as the patient is included in the decision-making process and has agreed to the treatment plan. While it is not yet widely embraced or used in practice ( Fawcett, 2020 ), concordance is recognised, not as a behaviour ( Rae, 2021 ) but more an approach or method which focuses on the equal partnership between patient and professional ( McKinnon, 2013 ) and enables effective and agreed treatment plans.

NICE last reviewed its guidance on medication adherence in 2019 and did not replace adherence with concordance within this. This supports the theory that adherence is an outcome of good concordance and the two are not synonyms. NICE (2009) guidelines, which are still valid, show evidence of concordant principles to maximise adherence. Integrating the theoretical principles of concordance into this case study demonstrates how the trainee advanced nurse practitioner aimed to individualise patient-centred care and improve health outcomes through optimising adherence.

Patient introduction and assessment

Jane (a pseudonym has been used to protect the patient's anonymity; Nursing and Midwifery Council (NMC) 2018 ), is a 45-year-old woman who had been referred to the surgery following an attendance at an emergency department. Jane had been role-playing as a patient as part of a teaching session for health professionals when it was noted that her blood pressure was significantly elevated at 170/88 mmHg. She had no other symptoms. Following an initial assessment at the emergency department, Jane was advised to contact her GP surgery for review and follow up. Nazarko (2021) recognised that it is common for individuals with high blood pressure to be asymptomatic, contributing to this being referred to as the ‘silent killer’. Hypertension is generally only detected through opportunistic checking of blood pressure, as seen in Jane's case, which is why adults over the age of 40 years are offered a blood pressure check every 5 years ( Bostock-Cox, 2013 ).

Consultation

Jane presented for a consultation at the surgery. Green (2015) advocates using a model to provide a structured approach to consultations which ensures quality and safety, and improves time management. Young et al (2009) claimed that no single consultation model is perfect, and Diamond-Fox (2021) suggested that, with experience, professionals can combine models to optimise consultation outcomes. Therefore, to effectively consult with Jane and to adapt to her individual personality, different models were intertwined to provide better person-centred care.

The Calgary–Cambridge model is the only consultation model that places emphasis on initiating the session, despite it being recognised that if a consultation gets off to a bad start this can interfere throughout ( Young et al, 2009 ). Being prepared for the consultation is key. Before Jane's consultation, the environment was checked to minimise interruptions, ensuring privacy and dignity ( Green, 2015 ; NMC, 2018 ), the seating arrangements optimised to aid good body language and communication ( Diamond-Fox, 2021 ) and her records were viewed to give some background information to help set the scene and develop a rapport ( Young et al, 2009 ). Being adequately prepared builds the patient's trust and confidence in the professional ( Donnelly and Martin, 2016 ) but equally viewing patient information can lead to the professional forming preconceived ideas ( Donnelly and Martin, 2016 ). Therefore, care was taken by the trainee advanced nurse practitioner to remain open-minded.

During Jane's consultation, a thorough clinical history was taken ( Table 1 ). History taking is common to all consultation models and involves gathering important information ( Diamond-Fox, 2021 ). History-taking needs to be an effective ( Bostock-Cox, 2019 ), holistic process ( Harper and Ajao, 2010 ) in order to be thorough, safe ( Diamond-Fox, 2021 ) and aid in an accurate diagnosis. The key skill for taking history is listening and observing the patient ( Harper and Ajao, 2010 ). Sir William Osler said:‘listen to the patient as they are telling you the diagnosis’, but Knott and Tidy (2021) suggested that patients are barely given 20 seconds before being interrupted, after which they withdraw and do not offer any new information ( Demosthenous, 2017 ). Using this guidance, Jane was given the ‘golden minute’ allowing her to tell her ‘story’ without being interrupted ( Green, 2015 ). This not only showed respect ( Ingram, 2017 ) but interest in the patient and their concerns.

Once Jane shared her story, it was important for the trainee advanced nurse practitioner to guide the questioning ( Green 2015 ). This was achieved using a structured approach to take Jane's history, which optimised efficiency and effectiveness, and ensured that pertinent information was not omitted ( Young et al, 2009 ). Thomas and Monaghan (2014) set out clear headings for this purpose. These included:

• The presenting complaint
• Past medical history
• Drug history
• Social history
• Family history.

McPhillips et al (2021) also emphasised a need for a systemic enquiry of the other body systems to ensure nothing is missed. From taking this history it was discovered that Jane had been feeling well with no associated symptoms or red flags. A blood pressure reading showed that her blood pressure was elevated. Jane had no past medical history or allergies. She was not taking any medications, including prescribed, over the counter, herbal or recreational. Jane confirmed that she did not drink alcohol or smoke. There was no family history to note, which is important to clarify as a genetic link to hypertension could account for 30–50% of cases ( Nazarko, 2021 ). The information gathered was summarised back to Jane, showing good practice ( McPhillips et al, 2021 ), and Jane was able to clarify salient or missing points. Green (2015) suggested that optimising the patient's involvement in this way in the consultation makes her feel listened to which enhances patient satisfaction, develops a therapeutic relationship and demonstrates concordance.

During history taking it is important to explore the patient's ideas, concerns and expectations. Moulton (2007) refers to these as the ‘holy trinity’ and central to upholding person-centredness ( Matthys et al, 2009 ). Giving Jane time to discuss her ideas, concerns and expectations allowed the trainee advanced nurse practitioner to understand that she was concerned about her risk of a stroke and heart attack, and worried about the implications of hypertension on her already stressful job. Using ideas, concerns and expectations helped to understand Jane's experience, attitudes and perceptions, which ultimately will impact on her health behaviours and whether engagement in treatment options is likely ( James and Holloway, 2020 ). Establishing Jane's views demonstrated that she was eager to engage and manage her blood pressure more effectively.

Vincer and Kaufman (2017) demonstrated, through their case study, that a failure to ask their patient's viewpoint at the initial consultation meant a delay in engagement with treatment. They recognised that this delay could have been avoided with the use of additional strategies had ideas, concerns and expectations been implemented. Failure to implement ideas, concerns and expectations is also associated with reattendance or the patient seeking second opinions ( Green, 2015 ) but more positively, when ideas, concerns and expectations is implemented, it can reduce the number of prescriptions while sustaining patient satisfaction ( Matthys et al, 2009 ).

Physical examination

Once a comprehensive history was taken, a physical examination was undertaken to supplement this information ( Nuttall and Rutt-Howard, 2016 ). A physical examination of all the body systems is not required ( Diamond-Fox, 2021 ) as this would be extremely time consuming, but the trainee advanced nurse practitioner needed to carefully select which systems to examine and use good examination technique to yield a correct diagnosis ( Knott and Tidy, 2021 ). With informed consent, clinical observations were recorded along with a full cardiovascular examination. The only abnormality discovered was Jane's blood pressure which was 164/90 mmHg, which could suggest stage 2 hypertension ( NICE, 2019 ; 2022 ). However, it is the trainee advanced nurse practitioner's role to use a hypothetico-deductive approach to arrive at a diagnosis. This requires synthesising all the information from the history taking and physical examination to formulate differential diagnoses ( Green, 2015 ) from which to confirm or refute before arriving at a final diagnosis ( Barratt, 2018 ).

Differential diagnosis

Hypertension can be triggered by secondary causes such as certain drugs (non-steroidal anti-inflammatory drugs, steroids, decongestants, sodium-containing medications or combined oral contraception), foods (liquorice, alcohol or caffeine; Jamison, 2006 ), physiological response (pain, anxiety or stress) or pre-eclampsia ( Jamison, 2006 ; Schroeder, 2017 ). However, Jane had clarified that these were not contributing factors. Other potential differentials which could not be ruled out were the white-coat syndrome, renal disease or hyperthyroidism ( Schroeder, 2017 ). Further tests were required, which included bloods, urine albumin creatinine ratio, electrocardiogram and home blood pressure monitoring, to ensure a correct diagnosis and identify any target organ damage.

Joint decision making

At this point, the trainee advanced nurse practitioner needed to share their knowledge in a meaningful way to enable the patient to participate with and be involved in making decisions about their care ( Rostoft et al, 2021 ). Not all patients wish to be involved in decision making ( Hobden, 2006 ) and this must be respected ( NMC, 2018 ). However, engaging patients in partnership working improves health outcomes ( McKinnon, 2013 ). Explaining the options available requires skill so as not to make the professional seem incompetent and to ensure the patient continues to feel safe ( Rostoft et al, 2021 ).

Information supported by the NICE guidelines was shared with Jane. These guidelines advocated that in order to confirm a diagnosis of hypertension, a clinic blood pressure reading of 140/90 mmHg or higher was required, with either an ambulatory or home blood pressure monitoring result of 135/85 mmHg or higher ( NICE, 2019 ; 2022 ). However, the results from a new retrospective study suggested that the use of home blood pressure monitoring is failing to detect ‘non-dippers’ or ‘reverse dippers’ ( Armitage et al, 2023 ). These are patients whose blood pressure fails to fall during their nighttime sleep. This places them at greater risk of cardiovascular disease and misdiagnosis if home blood pressure monitors are used, but ambulatory blood pressure monitors are less frequently used in primary care and therefore home blood pressure monitors appear to be the new norm ( Armitage et al, 2023 ).

Having discussed this with Jane she was keen to engage with home blood pressure monitoring in order to confirm the potential diagnosis, as starting a medication without a true diagnosis of hypertension could potentially cause harm ( Jamison, 2006 ). An accurate blood pressure measurement is needed to prevent misdiagnosis and unnecessary therapy ( Jamison, 2006 ) and this is dependent on reliable and calibrated equipment and competency in performing the task ( Bostock-Cox, 2013 ). Therefore, Jane was given education and training to ensure the validity and reliability of her blood pressure readings.

For Jane, this consultation was the ideal time to offer health promotion advice ( Green, 2015 ) as she was particularly worried about her elevated blood pressure. Offering health promotion advice is a way of caring, showing support and empowerment ( Ingram, 2017 ). Therefore, Jane was provided with information on a healthy diet, the reduction of salt intake, weight loss, exercise and continuing to abstain from smoking and alcohol ( Williams, 2013 ). These were all modifiable factors which Jane could implement straight away to reduce her blood pressure.

Safety netting

The final stage and bringing this consultation to a close was based on the fourth stage of Neighbour's (1987) model, which is safety netting. Safety netting identifies appropriate follow up and gives details to the patient on what to do if their condition changes ( Weiss, 2019 ). It is important that the patient knows who to contact and when ( Young et al, 2009 ). Therefore, Jane was advised that, should she develop chest pains, shortness of breath, peripheral oedema, reduced urinary output, headaches, visual disturbances or retinal haemorrhages ( Schroeder, 2017 ), she should present immediately to the emergency department, otherwise she would be reviewed in the surgery in 1 week.

Jane was followed up in a second consultation 1 week later with her home blood pressure readings. The average reading from the previous 6 days was calculated ( Bostock-Cox, 2013 ) and Jane's home blood pressure reading was 158/82 mmHg. This reading ruled out white-coat syndrome as Jane's blood pressure remained elevated outside clinic conditions (white-coat syndrome is defined as a difference of more than 20/10 mmHg between clinic blood pressure readings and the average home blood pressure reading; NICE, 2019 ; 2022 ). Subsequently, Jane was diagnosed with stage 2 essential (or primary) hypertension. Stage 2 is defined as a clinic blood pressure of 160/100 mmHg or higher or a home blood pressure of 150/95 mmHg or higher ( NICE, 2019 ; 2022 ).

A diagnosis of hypertension can be difficult for patients as they obtain a ‘sick label’ despite feeling well ( Jamison, 2006 ). This is recognised as a deterrent for their motivation to initiate drug treatment and lifestyle changes ( Williams, 2013 ), presenting a greater challenge to health professionals, which can be addressed through concordance strategies. However, having taken Jane's bloods, electrocardiogram and urine albumin:creatinine ratio in the first consultation, it was evident that there was no target organ damage and her Qrisk3 score was calculated as 3.4%. These results provided reassurance for Jane, but she was keen to engage and prevent any potential complications.

Agreeing treatment

Concordance is only truly practised when the patient's perspectives are valued, shared and used to inform planning ( McKinnon, 2013 ). The trainee advanced nurse practitioner now needed to use the information gained from the consultations to formulate a co-produced and meaningful treatment plan based on the best available evidence ( Diamond-Fox and Bone, 2021 ). Jane understood the risk associated with high blood pressure and was keen to begin medication as soon as possible. NICE guidelines ( 2019 ; 2022 ) advocate the use of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blockers in patients under 55 years of age and not of Black African or African-Caribbean origin. However, ACE inhibitors seem to be used as the first-line treatment for hypertensive patients under the age of 55 years ( O'Donovan, 2019 ).

ACE inhibitors directly affect the renin–angiotensin-aldosterone system which plays a central role in regulation of blood pressure ( Porth, 2015 ). Renin is secreted by the juxtaglomerular cells, in the kidneys' nephrons, when there is a decrease in renal perfusion and stimulation of the sympathetic nervous system ( O'Donovan, 2018 ). Renin then combines with angiotensinogen, a circulating plasma globulin from the liver, to form angiotensin I ( Kumar and Clark, 2017 ). Angiotensin I is inactive but, through ACE, an enzyme present in the endothelium of the lungs, it is transformed into angiotensin II ( Kumar and Clark, 2017 ). Angiotensin II is a vasoconstrictor which increases vascular resistance and in turn blood pressure ( Porth, 2015 ) while also stimulating the adrenal gland to produce aldosterone. Aldosterone reduces sodium excretion in the kidneys, thus increasing water reabsorption and therefore blood volume ( Porth, 2015 ). Using an ACE inhibitor prevents angiotensin II formation, which prevents vasoconstriction and stops reabsorption of sodium and water, thus reducing blood pressure.

When any new medication is being considered, providing education is key. This must include what the medication is for, the importance of taking it, any contraindications or interactions with the current medications being taken by the patient and the potential risk of adverse effects ( O'Donovan, 2018 ). Sharing this information with Jane allowed her to weigh up the pros and cons and make an informed choice leading to the creation of an individualised treatment plan.

Jamison (2006) placed great emphasis on sharing information about adverse effects, because patients with hypertension feel well before commencing medications, but taking medication has the potential to cause side effects which can affect adherence. Therefore, the range of side effects were discussed with Jane. These include a persistent, dry non-productive cough, hypotension, hypersensitivity, angioedema and renal impairment with hyperkalaemia ( Hitchings et al, 2019 ). ACE inhibitors have a range of adverse effects and most resolve when treatment is stopped ( Waterfield, 2008 ).

Following discussion with Jane, she proceeded with taking an ACE inhibitor and was encouraged to report any side effects in order to find another more suitable medication and to prevent her hypertension from going untreated. This information was provided verbally and written which is seen as good practice ( Green, 2015 ). Jane was followed up with fortnightly blood pressure recordings and urea and electrolyte checks and her dose of ramipril was increased fortnightly until her blood pressure was under 140/90 mmHg ( NICE, 2019 ; 2022 ).

Conclusions

Adherence to medications can be difficult to establish and maintain, especially for patients with long-term conditions. This can be particularly challenging for patients with hypertension because they are generally asymptomatic, yet acquire a sick label and start lifelong medication and lifestyle adjustments to prevent complications. Through adopting a concordant approach in practice, the outcome of adherence can be increased. This case study demonstrates how concordant strategies were implemented throughout the consultation to create a therapeutic patient–professional relationship. This optimised the creation of an individualised treatment plan which the patient engaged with and adhered to.

• Hypertension is a growing worldwide problem
• Appropriate clinical assessment, diagnosis and management is key to prevent misdiagnosis
• Long-term conditions are associated with high levels of non-adherence to treatments
• Adopting a concordance approach to practice optimises adherence and promotes positive patient outcomes

CPD reflective questions

• How has this article developed your assessment, diagnosis or management of patients presenting with a high blood pressure?
• What measures can you implement in your practice to enhance a concordant approach?

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Children's nursing case studies

Read first-hand stories from staff who work in a range of different children’s health specialties and nursing. Find out about the different routes to working in this area, with advice for anyone who is thinking of making the move into children’s nursing.

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• Case study: Adele Watkins, Mental Health Clinical Nurse Specialist for Women and Children at Noah Ark’s Children’s Hospital for Wales, Cardiff.
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• Case study: Christine Desmon, Advanced Nurse Practitioner – Paediatric Endocrinology at the Royal Berkshire Hospital, Reading.
• Case study: Claire Gillan, Clinical Educator and Liaison Nurse at Ulster Hospital, South Eastern Trust.
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• Case study: Pauline Nelson, Primary Mental Health Practitioner at Southern Health and Social Care Trust.
• Case study: Sarah Kvedaras, Paediatric Neurosurgical Clinical Nurse Specialist at Noah Ark’s Children’s Hospital for Wales.
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Practice learning experience case studies for nursing programmes

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Case studies

Trust implementation.

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Critical care

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Nursing Case Study

Ai generator.

ScienceDirect posted a nursing ethics case study where an end-stage prostate cancer patient, Mr. Green, confided to nursing staff about his plan to commit suicide. The patient asked the nurse to keep it a secret. The ethical problem is whether the nurse should tell the health care team members about the patient’s thought without his permission. The best ethical decision for this nursing case study was to share this critical information with other health care professionals, which was the action the nurse took. The team adhered to the proper self-harm and suicide protocol. The appropriate team performed a palliative therapy. As a result, the patient didn’t harm himself and died peacefully a few months after he was discharged.

What Is a Nursing Case Study? A nursing case study is a detailed study of an individual patient. Through this type of research, you can gain more information about the symptoms and the medical history of a patient. It will also allow you to provide the proper diagnoses of the patient’s illness based on the symptoms he or she experienced and other affecting factors. Nursing students usually perform this study as part of their practicum, making it an essential experience because, through this research methodology , they can apply the lessons they have learned from school. The situation mentioned above was an excellent example of a nursing case study.

Nursing Case Study Format

1. introduction.

Purpose: Briefly introduces the case study, including the main health issue or condition being explored. Background: Provides context for the patient scenario, outlining the significance of the case in nursing practice. Objectives: Lists the learning objectives or goals that the case study aims to achieve.

2. Patient Information

Demographics: Age, gender, ethnicity, and relevant personal information. Medical History: Past medical history, including any chronic conditions, surgeries, or significant health events. Current Health Assessment: Presents the patient’s current health status, including symptoms, vital signs, and results from initial examinations.

3. Case Description

Clinical Presentation: Detailed description of the patient’s presentation, including physical examination findings and patient-reported symptoms. Diagnostic Findings: Summarizes diagnostic tests that were performed, including lab tests, imaging studies, and other diagnostic procedures, along with their results. Treatment Plan: Outlines the initial treatment provided to the patient, including medications, therapies, surgeries, or other interventions.

4. Nursing Care Plan

Nursing Diagnoses: Identifies the nursing diagnoses based on the assessment data. Goals and Outcomes: Establishes short-term and long-term goals for the patient’s care, including expected outcomes. Interventions: Describes specific nursing interventions planned or implemented to address each nursing diagnosis and achieve the stated goals. Evaluation: Discusses the effectiveness of the nursing interventions, including patient progress and any adjustments made to the care plan.

5. Analysis

Critical Analysis: Analyzes the case in depth, considering different aspects of patient care, decision-making processes, and the application of nursing theories and principles. Reflection: Reflects on the nursing practice, lessons learned, and how the case study has impacted the understanding and application of nursing knowledge.

6. Conclusion

Summary: Provides a concise summary of the key points from the case study, including the patient outcome and the nursing care impact. Implications for Practice: Discusses the implications of the case for nursing practice, including any changes to practice or policy that could improve patient care. Recommendations: Offers recommendations for future care or areas for further study based on the case study findings.

Examples of Nursing Case Study

Management of Acute Myocardial Infarction (AMI) Introduction: A 58-year-old male with a history of hypertension and smoking presents to the emergency department with chest pain. This case study explores the nursing management for patients with AMI.   Patient Information: Demographics: 58-year-old male, smoker. Medical History: Hypertension, no previous diagnosis of heart disease. Current Health Assessment: Reports severe chest pain radiating to his left arm, sweating, and nausea.   Case Description: Clinical Presentation: Patient appeared in distress, clutching his chest. Diagnostic Findings: ECG showed ST-elevation in anterior leads. Troponin levels were elevated. Treatment Plan: Immediate administration of aspirin, nitroglycerin, and morphine for pain. Referred for emergency coronary angiography.   Nursing Care Plan: Nursing Diagnoses: Acute pain related to myocardial ischemia. Goals: Relieve pain and prevent further myocardial damage. Interventions: Monitoring vital signs, administering prescribed medications, and providing emotional support. Evaluation: Pain was managed effectively, and the patient was stabilized for angiography.   Analysis: The timely nursing interventions contributed to stabilizing the patient’s condition, showcasing the critical role nurses play in acute care settings.   Conclusion: This case highlights the importance of quick assessment and intervention in patients with AMI, emphasizing the nurse’s role in pain management and support.

Managing Type 1 Diabetes in a Pediatric Patient Introduction: A 10-year-old female diagnosed with type 1 diabetes presents for a routine check-up. This case study focuses on the nursing care plan for managing diabetes in pediatric patients.   Patient Information: Demographics: 10-year-old female. Medical History: Diagnosed with type 1 diabetes six months ago. Current Health Assessment: Well-controlled blood glucose levels, but expresses difficulty with frequent insulin injections.   Case Description: Clinical Presentation: Patient is active, engaging in school activities but struggles with diabetes management. Diagnostic Findings: HbA1c is 7.2%, indicating good control. Treatment Plan: Insulin therapy, carbohydrate counting, and regular blood glucose monitoring.   Nursing Care Plan: Nursing Diagnoses: Risk for unstable blood glucose levels. Goals: Maintain blood glucose within target range and increase patient comfort with diabetes management. Interventions: Education on insulin pump use, dietary advice, and coping strategies. Evaluation: Patient showed interest in using an insulin pump and understood dietary recommendations.   Analysis: This case emphasizes the importance of education and emotional support in managing chronic conditions in pediatric patients.   Conclusion: Effective management of type 1 diabetes in children requires a comprehensive approach that includes education, technological aids, and psychological support.

Elderly Care for Alzheimer’s Disease Introduction: An 82-year-old female with Alzheimer’s disease presents with increased confusion and agitation. This case study examines the complexities of caring for elderly patients with Alzheimer’s.   Patient Information: Demographics: 82-year-old female. Medical History: Alzheimer’s disease, osteoarthritis. Current Health Assessment: Increased confusion, agitation, and occasional aggression.   Case Description: Clinical Presentation: Patient exhibits signs of advanced Alzheimer’s with memory loss and disorientation. Diagnostic Findings: Cognitive tests confirm the progression of Alzheimer’s. Treatment Plan: Non-pharmacological interventions for agitation, memory aids, and safety measures in the home.   Nursing Care Plan: Nursing Diagnoses: Impaired memory related to Alzheimer’s disease. Goals: Reduce agitation and prevent harm. Interventions: Use of calming techniques, establishing a routine, and environmental modifications. Evaluation: Agitation was reduced, and the patient’s safety was improved through environmental adjustments.   Analysis: The case underscores the need for tailored interventions to manage Alzheimer’s symptoms and improve the quality of life for the elderly.   Conclusion: Nursing care for Alzheimer’s patients requires a multifaceted approach focusing on safety, symptom management, and patient dignity.

Nursing Case Study Topics with Samples to Edit & Download

• Telehealth Nursing
• Mental Health and Psychiatric Nursing
• Geriatric Nursing Care
• Palliative and End-of-Life Care
• Pediatric Nursing
• Emergency and Critical Care Nursing
• Chronic Disease Management
• Nursing Ethics and Patient Rights
• Infection Control and Prevention
• Oncology Nursing
• Nursing Leadership and Management
• Cultural Competence in Nursing
• Substance Abuse and Addiction Nursing
• Technological Innovations in Nursing
• Nursing Education and Training

Nursing Case Study Examples & Templates

1. nursing case study template.

2. Free Nursing Student Care Plan Template

3. Nursing Action Case Study Example

4. Hospital Nursing Care Case Study Example

5. Printable Nursing Health Case Study Example

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6. Fundamentals of Nursing Case Study Example

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7. Sample Nursing Case Study Example

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8. Nursing Research Case Study Example

9. Standard Nursing Case Study Example

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10. Nursing Disability Case Study Example

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11. Nursing care Patients Case Study Example

12. School of Nursing Case Study Example

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13. Evaluation of Nursing Care Case Study Example

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Nursing Case Study Segments

Typically, a nursing case study contains three main categories, such as the items below.

1. The Status of a Patient

In this section, you will provide the patient’s information, such as medical history, and give the current patient’s diagnosis, condition, and treatment. Always remember to write down all the relevant information about the patient. Other items that you can collect in this stage are the reasons for the patient to seek medical care and the initial symptoms that he or she is experiencing. After that, based on the gathered information, you will explain the nature and cause of the illness of the patient.

2. The Nursing Assessment of the Patient

In this stage, you will need to prepare your evaluation of the patient’s condition. You should explain each observation that you have collected based on the vital signs and test results. You will also explain each nursing diagnosis that you have identified and determine the proper nursing care plan for the patient.

3. The Current Care Plan and Recommendations

Describe the appropriate care plan that you can recommend to the patient based on the diagnosis, current status, and prognosis in detail, including how the care plan will affect his or her life quality. If needed, you can also evaluate the patient’s existing care plan and give recommendations to enhance it. It is also crucial to cite relevant authoritative sources that will support your recommendations .

Objectives of Nursing Case Study

Nursing case studies are integral educational tools that bridge theoretical knowledge with practical application in patient care. They serve several key objectives essential for the development of nursing students and professionals. Here are the primary objectives of nursing case studies:

1. Enhance Critical Thinking and Clinical Reasoning

Case studies encourage nurses to analyze complex patient scenarios, make informed decisions, and apply critical thinking skills to solve problems. They simulate real-life situations, requiring nurses to evaluate data, consider multiple outcomes, and choose the best course of action.

2. Improve Diagnostic Skills

Through the detailed analysis of patient information, symptoms, and diagnostic results, nursing case studies help improve diagnostic skills. They allow nurses to practice interpreting clinical data to identify patient conditions and understand the underlying causes of symptoms.

3. Facilitate Application of Theoretical Knowledge

Nursing case studies provide a direct bridge between classroom learning and clinical practice. They offer a practical venue for applying theoretical knowledge about anatomy, physiology, pharmacology, and nursing theories to real-world patient care situations.

4. Promote Understanding of Comprehensive Patient Care

These studies emphasize the importance of holistic care, considering the physical, emotional, social, and psychological aspects of patient well-being. Nurses learn to develop comprehensive care plans that address all facets of a patient’s health.

5. Encourage Reflective Practice and Self-Assessment

Reflecting on case study outcomes enables nurses to evaluate their own decision-making processes, clinical judgments, and actions. This self-assessment promotes continuous learning and professional growth by identifying areas for improvement.

6. Foster Interdisciplinary Collaboration

Case studies often involve scenarios that require collaboration among healthcare professionals from various disciplines. They teach nurses the value of teamwork, communication, and the integration of different expertise to achieve optimal patient outcomes.

7. Enhance Patient Education and Advocacy Skills

By working through case studies, nurses improve their ability to educate patients and families about health conditions, treatment plans, and preventive measures. They also learn to advocate for their patients’ needs and preferences within the healthcare system.

8. Prepare for Real-Life Challenges

Nursing case studies prepare students and new nurses for the unpredictability and challenges of real-life clinical settings. They provide safe, controlled environments to practice responses to emergencies, ethical dilemmas, and complex patient needs without the risk of actual harm.

Steps in Nursing Process

Whether you are handling a patient with schizophrenia, pneumonia, diabetes, appendicitis, hypertension, COPD, etc, you will need to follow specific steps to ensure that you are executing the critical nursing process.

1. Assess the Patient

The first step of the nursing process requires critical thinking skills as it involves gathering both subjective and objective data. Subjective data includes verbal statements that you can collect from the patient or caregiver. In contrast, objective information refers to measurable and tangible data, such as vital signs, height, weight, etc. You can also use other sources of information, such as electronic health records, and friends that are in direct contact with the patient.

2. Diagnose the Patient

This critical step will help you in the next steps, such as planning and implementation of patient care. In this step, you will formulate a nursing diagnosis by applying clinical judgment. As a nurse, the North American Nursing Diagnosis Association (NANDA) will give you an up-to-date nursing diagnosis list, which will allow you to form a diagnosis based on the actual health problem.

3. Plan for a Proper Patient Care Plan

This part is where you will plan out the appropriate care plan for the patient. You will set this goal following the evidence-based practice (EDP) guidelines. The goal you will set should be specific, measurable, attainable, realistic, and timely ( SMART ).

4. Implement the Plan

In this stage, you can execute the plan that you have developed in the previous step. The implementation may need interventions such as a cardiac monitor, medication administration, etc.

5. Evaluate the Results

It is crucial to remember that every time the team does an intervention, you must do a reassessment to ensure that the process will lead to a positive result. You may need to reassess the patient depending on his progress, and the care plan may be modified based on the reassessment result.

Where to find nursing case studies?

Nursing case studies can be found in a variety of academic, professional, and medical resources. Here are some key places to look for nursing case studies:

• Academic Journals : Many academic journals focus on nursing and healthcare and publish case studies regularly. Examples include the “Journal of Clinical Nursing,” “Nursing Case Studies,” and “American Journal of Nursing.”
• University and College Libraries : Many academic institutions provide access to databases and journals that contain nursing case studies. Libraries often have subscriptions to these resources.
• Online Medical Libraries : Websites like PubMed, ScienceDirect, and Wiley Online Library offer a vast collection of nursing and medical case studies.
• Professional Nursing Organizations : Organizations such as the American Nurses Association (ANA) and the National League for Nursing (NLN) often provide resources, including case studies, for their members.
• Nursing Education Websites : Websites dedicated to nursing education, such as Lippincott NursingCenter and Nurse.com, often feature case studies for educational purposes.
• Government Health Websites : The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) sometimes publish case studies related to public health nursing and disease outbreaks.
• Nursing Textbooks and eBooks : Many nursing textbooks and eBooks include case studies to illustrate key concepts and scenarios encountered in practice.
• Online Nursing Forums and Communities : Forums and online communities for nursing professionals may share or discuss case studies as part of their content.
• Conference Proceedings : Nursing and healthcare conferences often include presentations of case studies. Many of these are published in the conference proceedings, which may be accessible online.

Carrying out a nursing case study can be a delicate task since it puts the life of a person at stake. Thus, it requires a thorough investigation. With that said, it is essential to gain intensive knowledge about this type of study. Today, we have discussed an overview of how to conduct a nursing case study. However, if you think that you are having problems with your writing skills , we recommend you to consider looking for an essay writing service from the experts in the nursing department to ensure that the output follows the appropriate writing style and terminology.

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Urinary tract infection in an older patient: a case study and review

Advanced Nurse Practitioner, Primary Care

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Gerri Mortimore

Senior lecturer in advanced practice, department of health and social care, University of Derby

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This article will discuss and reflect on a case study involving the prescribing of nitrofurantoin, by a non-medical prescriber, for a suspected symptomatic uncomplicated urinary tract infection in a patient living in a care home. The focus will be around the consultation and decision-making process of prescribing and the difficulties faced when dealing with frail, uncommunicative patients. This article will explore and critique the evidence-base, local and national guidelines, and primary research around the pharmacokinetics and pharmacodynamics of nitrofurantoin, a commonly prescribed medication. Consideration of the legal, ethical and professional issues when prescribing in a non-medical capacity will also be sought, concluding with a review of the continuing professional development required to influence future prescribing decisions relating to the case study.

Urinary tract infections are common in older people. Haley Read and Gerri Mortimore describe the decision making process in the case of an older patient with a UTI

One of the growing community healthcare delivery agendas is that of the advanced nurse practitioner (ANP) role to improve access to timely, appropriate assessment and treatment of patients, in an attempt to avoid unnecessary health deterioration and/or hospitalisation ( O'Neill et al, 2021 ). The Core Capabilities Framework for Advanced Clinical Practice (Nurses) Working in General Practice/Primary Care in England recognises the application of essential skills, including sound consultation and clinical decision making for prescribing appropriate treatment ( Health Education England [HEE], 2020 ). This article will discuss and reflect on a case study involving the prescribing of nitrofurantoin by a ANP for a suspected symptomatic uncomplicated urinary tract infection (UTI), in a patient living in a care home. Focus will be around the consultation and decision-making process of non-medical prescribing and will explore and critique the evidence-base, examining the local and national guidelines and primary research around the pharmacokinetics and pharmacodynamics of nitrofurantoin. Consideration of the legal, ethical and professional issues when prescribing in a non-medical capacity will also be sought, concluding with review of the continuing professional development required to influence future prescribing decisions relating to the case study.

Mrs M, an 87-year-old lady living in a nursing home, was referred to the community ANP by the senior carer. The presenting complaint was reported as dark, cloudy, foul-smelling urine, with new confusion and night-time hallucinations. The carer reported a history of disturbed night sleep, with hallucinations of spiders crawling in bed, followed by agitation, lethargy and poor oral intake the next morning. The SBAR (situation, background, assessment, recommendation) tool was adopted, ensuring structured and relevant communication was obtained ( NHS England and NHS Improvement, 2021 ). The National Institute for Health and Care Excellence ( NICE, 2021 ) recognises that cloudy, foul-smelling urine may indicate UTI. Other symptoms include increased frequency or pressure to pass urine, dysuria, haematuria or dark coloured urine, mild fever, night-time urination, and increased sweats or chills, with lower abdominal/loin pain suggesting severe infection. NICE (2021) highlight that patients with confusion may not report UTI symptoms. This is supported by Gupta and Gupta (2019) , who recognise new confusion as hyper-delirium, which can be attributed to several causative factors including infection, dehydration, constipation and medication, among others.

UTIs are one of the most common infections worldwide ( O'Grady et al, 2019 ). Lajiness and Lajiness (2019) define UTI as a presence of colonising bacteria that cause a multitude of symptoms affecting either the upper or lower urinary tract. NICE (2021) further classifies UTIs as either uncomplicated or complicated, with complicated involving other systemic conditions or pre-existing diseases. Geerts et al (2013) postulate around 30% of females will develop a UTI at least once in their life. The incidence increases with age, with those over 65 years of age being five times more likely to develop a UTI at any point. Further increased prevalence is found in patients who live in a care home, with up to 60% of all infections caused by UTI ( Bardsley, 2017 ).

Greener (2011) reported that symptoms of UTIs are often underestimated by clinicians. A study cited by Greener (2011) found over half of GPs did not record the UTI symptoms that the patient had reported. It is, therefore, essential during the consultation to use open-ended questions, listening to the terminology of the patient or carers to clarify the symptoms and creating an objective history ( Taylor, 2016 ).

In this case, the carer highlighted that Mrs M had been treated for suspected UTI twice in the last 12 months. Greener (2011) , in their literature review of 8 Cochrane review papers and 1 systematic review, which looked at recurrent UTI incidences in general practice, found 48% of women went on to have a further episode within 12 months.

Mrs M's past medical history reviewed via the GP electronic notes included:

• Hypertension
• Diverticular disease
• Basal cell carcinoma of scalp
• Retinal vein occlusion
• Severe frailty
• Fracture of proximal end of femur
• Total left hip replacement
• Previous indwelling urinary catheter
• Chronic kidney disease (CKD) stage 2
• Urinary and faecal incontinence
• And, most recently, vesicovaginal fistula.

Bardsley (2017) identified further UTI risk factors including postmenopausal females, frailty, co-morbidity, incontinence and use of urethral catheterisation. Vesicovaginal fistulas also predispose to recurrent UTIs, due to the increase in urinary incontinence ( Stamatokos et al, 2014 ). Moreover, UTIs are common in older females living in a care home ( Bradley and Sheeran, 2017 ). They can cause severe risks to the patient if left untreated, leading to complications such as pyelonephritis or sepsis ( Ahmed et al, 2018 ).

Mrs M's medication included:

• Paracetamol 1 g as required
• Lactulose 10 ml twice daily
• Docusate 200 mg twice daily
• Epimax cream
• Colecalciferol 400 units daily
• Alendronic acid 70 mg weekly.

She did not take any herbal or over the counter preparations. Her records reported no known drug allergies; however, she was allergic to Elastoplast. A vital part of clinical history involves reviewing current prescribed and non-prescribed medications, herbal remedies and drug allergies, to prevent contraindications or reactions with potential prescribed medication ( Royal Pharmaceutical Society, 2019 ). Several authors, including Malcolm et al (2018) , indicate polypharmacy as a common cause of adverse drug reactions (ADRs), worsening health and affecting a person's quality of life. NICE (2015) only recommends review of patients who are on four or more medications on each new clinical intervention, not taking into account individual drug interactions.

Due to Mrs M's lack of capacity, her social history was obtained via the electronic record and the carer. She moved to the care home 3 years ago, following respite care after her fall and hip replacement. She had never smoked or drank alcohol. Documented family history revealed stroke, ischaemic heart disease and breast cancer. Taylor (2016) reports a good thorough clinical history can equate to 90% of the working diagnosis before examination, potentially reducing unnecessary tests and investigations. This can prove challenging when the patient has confusion. It takes a more investigative approach, gaining access to medical/nursing care notes, and using family or carers to provide further collateral history ( Gupta and Gupta, 2019 ).

As per NICE (2021) guidelines, a physical examination of Mrs M was carried out. On examination it was noted that Mrs M had mild pallor with normal capillary refill time, no signs of peripheral or central cyanosis, and no clinical stigmata to note. Her heart rate was elevated at 112 beats per minute and regular, she had a normal respiration rate of 17 breaths per minute, oxygen saturations (SpO 2 ) were 98% on room air and blood pressure was 116/70 mm/Hg. Her temperature was 37.3oC. According to Doyle and Schortgen (2016) , there is no agreed level of fever; however, it becomes significant when above 38.3oC. Bardsley (2017) adds that older patients do not always present with pyrexia in UTI because of an impaired immune response.

Heart and chest sounds were normal, with no peripheral oedema. The abdomen was non-distended, soft and non-tender on palpation, with no reports of nausea, vomiting, supra-pubic tenderness or loin pain. Loin pain or suprapubic tenderness can indicate pyelonephritis ( Bardsley, 2017 ). Tachycardia, fever, confusion, drowsiness, nausea/vomiting or tachypnoea are strong predictive signs of sepsis ( NICE, 2021 ).

During the consultation, confusion and restlessness were evident. Therefore, it was difficult to ask direct questions to Mrs M regarding pain, nausea and dizziness. Non-verbal cues were considered, as changes in behaviour and restlessness can potentially highlight discomfort or pain ( Swift, 2018 ).

Mrs M's most recent blood tests indicated CKD stage 2, based on an estimated glomerular filtration rate (eGFR) of 82 ml/minute/1.73m 2 . The degree of renal function is vital to establish prior to any prescribing decision, because of the potential increased risk of drug toxicity ( Doogue and Polasek, 2013 ). The agreed level of mild renal impairment is when eGFR is <60 ml/minute/1.73 m 2 , with chronic renal impairment established when eGFR levels are sustained over a 3-month period ( Ahmed et al, 2018 ).

Previous urine samples of Mrs M grew Escherichia coli bacteria, sensitive to nitrofurantoin but resistant to trimethoprim. A consensus of papers, including Lajiness and Lajiness (2019) , highlight the most common pathogen for UTI as E. coli. Fransen et al (2016) indicates that increased use of empirical antibiotics has led to a prevalence of extended spectrum beta lactamase positive (ESBL+) bacteria that are resistant to many current antibiotics. This is not taken into account by the NICE guidelines (2021) ; however, it is discussed in local guidelines ( Barnsley Hospital NHS FT/Rotherham NHS FT, 2022 ).

Mrs M was unable to provide an uncontaminated urine sample due to incontinence. NICE (2021) advocate urine culture as a definitive diagnostic tool for UTIs; however, do not highlight how to objectively obtain this. Bardsley (2017) recognises the benefit of an uncontaminated urinalysis in symptomatic patients, stating that alongside other clinical signs, nitrates and leucocytes strongly predict the possibility of UTI. O'Grady et al (2019) points out that although NICE emphasise urine culture collection, it omits the use of urinalysis as part of the assessment.

Based on Ms M's clinical history and physical examination, a working diagnosis of suspected symptomatic uncomplicated UTI was hypothesised. A decision was made, based on the local antibiotic prescribing guidelines, as well as the NICE (2021) guidelines, to treat empirically with nitrofurantoin modified release (MR), 100 mg twice daily for 3 days, to avoid further health or systemic complications. The use of electronic prescribing was adopted as per local organisational policy and the Royal Pharmaceutical Society (2019) . Electronic prescribing is essential for legibility and sharing of prescribing information. It also acts as an audit on prescribing practices, providing a contemporaneous history for any potential litigation ( Lovatt, 2010 ).

Pharmacokinetics and pharmacodynamics

Lajiness and Lajiness (2019) reflect on the origins of nitrofurantoin back to the 1950s, following high penicillin usage leading to resistance of Gram-negative bacteria. Nitrofurantoin has been the first-line empirical treatment for UTIs internationally since 2010, despite other antibacterial agents being discovered ( Wijma et al, 2020 ). Mckinell et al (2011) highlight that a surge in bacterial resistance brought about interest in nitrofurantoin as a first-line option. Their systematic review of the literature indicated through a cost and efficacy decision analysis that nitrofurantoin was a low resistance and low cost risk; therefore, an effective alternative to trimethoprim or fluoroquinolones. The weakness of this paper is the lack of data on nitrofurantoin cure rates and resistance studies, demonstrating an inability to predict complete superiority of nitrofurantoin over other antibiotics. This could be down to the reduced use of nitrofurantoin treatment at the time.

Fransen et al (2016) reported that minimal pharmacodynamic knowledge of nitrofurantoin exists, despite its strong evidence-based results against most common urinary pathogens, and being around for the last 70 years. Wijma et al (2018) hypothesised this was because of the lack of drug approval requirements in the era when nitrofurantoin was first produced, and the growing incidence of antibiotic resistance. Pharmacokinetics and pharmacodynamics are clinically important to guide effective drug therapy and avoid potential ADRs. Focus on the absorption, distribution, metabolism and excretion (ADME) of nitrofurantoin is needed to evaluate the correct choice for an individual patient, based on a holistic assessment ( Doogue and Polasek, 2013 ).

Nitrofurantoin is structurally made up of 4 carbon and 1 oxygen atoms forming a furan ring, connected to a nitrogroup (–NO 2 ). Its mode of action is predominantly bacteriostatic, with some bactericidal tendencies in high concentration levels ( Wijma et al, 2018 ). It works by inhibiting bacterial cell growth, breaking down its strands of DNA ( Komp Lindgren et al, 2015 ). Hoang and Salbu (2016) add that nitrofurantoin causes bacterial flavoproteins to create reactive medians that halt bacterial ribosomal proteins, rendering DNA/RNA cell wall synthesis inactive.

Nitrofurantoin is administered orally via capsules or liquid. Greener (2011) highlights the different formulations, which originally included microcrystalline tablets and now include macro-crystalline capsules. The increased size of crystals was found to slow absorption rates down ( Hoang and Salbu, 2016 ). Nitrofurantoin is predominantly absorbed via the gastro-intestinal tract, enhanced by an acidic environment. It is advised to take nitrofurantoin with food, to slow down gastric emptying ( Wijma et al, 2018 ). The maximum blood concentration of nitrofurantoin is said to be <0.6 mg/l. Lower plasma concentration equates to lower toxicity risk; therefore, nitrofurantoin is favourable over fluoroquinolones ( Komp Lindgren et al, 2015 ). Wijma et al (2020) found a reduced effect on gut flora compared to fluoroquinolones.

Distribution of nitrofurantoin is mainly via the renal medulla, with a renal bioavailability of 38.8–44%; therefore, it is specific for urinary action ( Hoang and Salbu, 2016 ). Haasum et al (2013) highlight the inability for nitrofurantoin to penetrate the prostate where bacteria concentration levels can be present. Therefore, they do not advocate the use of nitrofurantoin to treat males with UTIs, because of the risk of treatment failure and further complications of systemic infection. This did not appear to be addressed by local guidelines.

The metabolism of nitrofurantoin is not completely understood; however, Wijma et al (2018) indicate several potential metabolic antibacterial actions. Around 0.8–1.8% is metabolised into aminofurantoin, with 80.9% other unknown metabolites ( medicines.org, 2022 ). Wijma et al (2020) calls for further study into the metabolism of nitrofurantoin to aid understanding of the pharmacodynamics.

Excretion of nitrofurantoin is predominantly via urine, with a peak time of 4–5 hours, and 27–50% excreted unchanged in urine ( medicines.org, 2022 ). Komp Lindgren et al (2015) equates the fast rates of renal availability and excretion to lower toxicity risks and targeted treatment for UTI pathogens. Wijma et al (2018) found high plasma concentration levels of nitrofurantoin in renal impairment. Singh et al (2015) indicate that nitrofurantoin is mainly eliminated via glomerular filtration; therefore, its impairment presents the potential risks of treatment failure and increased ADRs. Early guidelines stipulated the need to avoid nitrofurantoin in patients with mild renal impairment, indicating the need for an eGFR of >60 ml/min due to this toxicity risk. This was based on several small studies, cited by Hoang and Salbu (2016) , looking at concentration levels rather than focused on patient treatment outcomes.

Primary research by Geerts et al (2013) involving treatment outcomes in a large cohort study, led to guidelines changing the limit to mild to moderate impairment or eGFR >45 ml/min. However, the risk of ADRs, including pulmonary fibrosis and hepatic changes, were increased in renal insufficiency with prolonged use. The study participants had a mean age of 47.8 years; therefore, the study did not indicate the effects on older patients. Singh et al (2015) presented a Canadian study, looking at treatment success with nitrofurantoin in older females, with a mean age of 79 years. It indicated effective treatment despite mild/moderate renal impairment. It did not address the levels of ADRs or hospitalisation. Ahmed et al (2018) conducted a large, UK-based, retrospective cohort study favouring use of empirical nitrofurantoin in the older population with increased risk of UTI-related hospitalisation and mild/moderate renal impairment. It concluded not treating could increase mortality and morbidity. This led to guidelines to support empirical treatment of symptomatic older patients with nitrofurantoin.

Dosing is highly variable between the local and national guidelines. Greener (2011) highlights that product information for the macro-crystalline capsules recommends 50–100 mg 4 times a day for 7 days when treating acute uncomplicated UTI. Local guidelines from Barnsley Hospital NHS FT/Rotherham NHS FT Adult antimicrobial guide (2022) stipulate 50–100 mg 4 times daily for 3 days for women, whereas NICE (2021) recommends a MR version of 100 mg twice daily for 3 days.

In a systematic literature review on the pharmacokinetics of nitrofurantoin, Wijma et al (2018) found that use of a 5–7 day course had similar strong efficacy rates, whereas 3 days did not, potentially causing treatment failure, equating to poor patient outcomes and resistant behaviour. Deresinski (2018) conducted a small, randomised controlled trial involving 377 patients either on nitrofurantoin MR 100 mg three times a day for 5 days or fosfomycin single dose treatment after urinalysis and culture. It looked at response to treatment after 28 days. Nitrofurantoin was found to have a 78% cure rate compared to 50% with fosfomycin. Therefore, these studies directly contradict current NICE and local guidelines on treatment dosing of UTI in women. More robust studies on dosing regimens are therefore required.

Fransen et al (2016) conducted a non-human pharmacodynamics study looking at time of action to treat on 11 strains of common UTI bacteria including two ESBL+. It demonstrated the kill rate for E. coli was 16–24 hours, slower than Enterobacter cloacae (6–8 hours) and Klebsiella pneumoniae (8 hours). The findings also indicated that nitrofurantoin appeared effective against ESBL+. Dosing and urine concentrations were measured, and found that 100 mg every 6 hours kept the urine concentration levels significant enough to reach peak levels. This study directly contradicted the findings of Lindgren et al (2015) , who conducted similar non-human kinetic style kill rate studies, and found nitrofurantoin's dynamic action to be within 6 hours for E. coli. Both studies have limitations in that they did not take into account human immune response effects.

Wijma et al (2020) highlighted inconsistent dosing regimens in their retrospective audit involving 150 patients treated for UTIs across three Australian secondary care facilities. The predominant dosing of nitrofurantoin was 100 mg twice daily for 5 days for women and 7 days for males. Although a small audit-based paper, it creates debate regarding the lack of clarity around the correct dosing, leaving it open to error. It therefore requires primary research into the follow up of cure rates on guideline prescribing regimens. Dose and timing remains an important issue to reduce treatment failure. It indicates the need for bacteria-dependant dosing, which currently NICE (2021) does not discuss.

Haasum et al (2013) found poor adherence to guidelines for choice and dosing in elderly patients in their Swedish register-based large population study. It highlighted high use of trimethoprim in frail older care home residents, despite guidelines recommending nitrofurantoin as first-line. A recent retrospective, observational, quantitative study by Langner et al (2021) involving 44.9 million women treated for a UTI in the USA across primary and secondary care, found an overuse of fluoroquinolones and underuse of nitrofurantoin and trimethoprim, especially by primary care physicians for older Asian and socio-economically deprived patients. Both these studies did not seek a true qualitative rationale for choices of antibiotics; therefore, limiting the findings.

Legal and ethical considerations

NMP regulation of best practice is set by the Royal Pharmaceutical Society framework (2019) , incorporating several acts of law including the medicines act 1968, and medicinal products prescribed by the Nurses Act (1992). As per Nursing Midwifery Council (2021) Code of Conduct and Health Education England (2020), ANPs have a duty of care to patients, ensuring that they work within their area of competence and recognise any limitations, demonstrating accountability for decisions made ( Lovatt, 2010 ).

Empirical treatment of UTIs is debated in the literature. O'Grady et al (2019) summarises that empirical treatment can reduce further UTI complications that can lead to acute health needs and hospitalisation, without increased risk of antibiotic resistance. Greener (2011) states that uncomplicated UTIs can be self-limiting; therefore, not always warranting antibiotic treatment if sound self-care advice is adopted. Chardavoyne and Kasmire (2020) discuss delayed prescribing, involving putting the onus on the patient and carers, which was not advisable in the case of Mrs M. Bradley and Sheeran (2017) found that three quarters of antibiotics in care home residents were prescribed inaccurately, hence recommended a watch and wait approach to treatment in the older care home resident, following implementation of a risk reduction strategy.

Taylor (2016) recommended an individual, holistic approach, incorporating ethical considerations such as choice, level of concordance, understanding and agreement of treatment choice. This can prove difficult in a case such as Mrs M. If a patient is deemed to lack capacity, a decision to act in the patient's best interest should be applied ( Gupta and Gupta, 2019 ). Therefore, understanding a patient's beliefs and values via family or carers should be explored, balancing the needs and possible outcomes. The principle of non-maleficence should be adopted, looking at risks versus benefits on prescribing the antibiotic to the individual patient ( Royal Pharmaceutical Society, 2019 ).

Non-pharmacological advice was provided to the carers to ensure that Mrs M maintained good fluid intake of 2 litres in 24 hours. NICE (2021) advocates the use of written self-care advice leaflets that have been produced to educate patients and/or carers on non-pharmacological actions, supporting recovery and improving outcomes. The use of paracetamol for symptoms of fever and/or pain was also recommended for Mrs M. Prevention strategies proposed by Lajiness and Lajiness (2019) included looking at the benefits of oestrogen cream in post-menopausal women in reducing the incidence of UTIs. Cranberry juice, probiotics and vitamin C ingestion are not supported by any strong evidence base.

There is a duty of care to ensure that follow up of the patient during and after treatment is delivered by the NMP ( Chardavoyne and Kasmire, 2020 ). Clinical safety netting advice was discussed with the carers to monitor Mrs M for any deterioration, and to seek further clinical review urgently. Particular attention to signs of ADRs and sepsis, and the need for 999 response if these occurred, was advocated. A treatment plan was also sent to the GP to ensure sound communication and continuation of safe care ( Taylor, 2016 ).

Professional development issues

The extended role of prescribing brings additional responsibility, with onus on both the NMP and the employer vicariously, to ensure key skills are updated. This is where continued professional development involving research, training and knowledge is sought and applied, using evidence-based, up-to-date practice ( HEE, 2020 ). Adoption of antibiotic stewardship is highlighted by several papers including Lajiness and Lajiness (2019) . They advise nine points to consider, to increase knowledge around the actions and consequences of the drug by the prescriber. Despite no acknowledgment in NICE (2021) guidance, previous results of infections and sensitivities are also proposed as vital in antibiotic stewardship.

The use of decision support tools, proposed by Malcolm et al (2018) , involves an audit approach looking at antibiograms, that highlight local microbiology resistance patterns to aid antibiotic choices, alongside a risk reduction team strategy. Bradley and Sheeran (2017) looked at improving antibiotic use for UTI treatment in a care home in Pennsylvania. They employed a programme of monitoring and educating clinical staff, patients, carers and relatives in evidence-based self-care and clinical assessment skills over a 30-month period. It demonstrated a reduction in inappropriate antibiotic prescribing, and an improvement in monitoring symptoms and self-care practices, creating better patient outcomes. It was evaluated highly by nursing staff, who reported a sense of autonomy and confidence involving team work. Langner et al (2021) calls for further education and feedback to prescribers, involving pharmacists and microbiology data to identify and understand patterns of prescribing.

UTIs can be misdiagnosed and under- or over-treated, despite the presence of local and national guidelines. Continued monitoring of nitrofurantoin use requires priority, due to its first-line treatment status internationally, as this may increase reliance and overuse of the drug, with potential for resistant strains of bacteria becoming prevalent.

Diligent clinical assessment skills and prescribing of appropriate treatment is paramount to ensure risk of serious complications, hospitalisation and mortality are reduced, while quality of life is maintained. The use of competent clinical practice, up-to-date evidence-based knowledge, good communication and understanding of individual patient needs, and concordance are essential to make sound prescribing choices to avoid harm. As well as the prescribing of medications, the education, monitoring and follow-up of the patient and prescribing practices are equally a vital part of the autonomous role of the NMP.

KEY POINTS:

• Urinary tract infections (UTIs) can be misdiagnosed and under- or over-treated, despite the presence of local and national guidelines
• The incidence of UTI increases with age, with those over 65 years of age being five times more likely to develop a UTI at any point
• Nitrofurantoin has been the first-line empirical treatment for UTIs internationally since 2010. Its mode of action is predominantly bacteriostatic, with some bactericidal tendencies in high concentration levels
• Diligent clinical assessment skills and prescribing of appropriate treatment is paramount to ensure risk of serious complications, hospitalisation and mortality are reduced, while quality of life is maintained

CPD REFLECTIVE PRACTICE:

• How can a good clinical history be gained if the patient lacks capacity?
• What factors need to be considered when safety netting in cases like this?
• What non-pharmacological advice would you give to a patient with a urinary tract infection (or their carers)?
• How will this article change your clinical practice?

• Open access
• Published: 06 June 2024

Multi-stage optimization strategy based on contextual analysis to create M-health components for case management model in breast cancer transitional care: the CMBM study as an example

• Hong Chengang 1 ,
• Wang Liping 1 ,
• Wang Shujin 1 ,
• Chen Chen 1 ,
• Yang Jiayue 1 ,
• Lu Jingjing 1 ,
• Hua Shujie 1 ,
• Wu Jieming 1 ,
• Yao Liyan 1 ,
• Zeng Ni 1 ,
• Chu Jinhui 1 &
• Sun Jiaqi 1  

BMC Nursing volume  23 , Article number:  385 ( 2024 ) Cite this article

Metrics details

None of the early M-Health applications are designed for case management care services. This study aims to describe the process of developing a M-health component for the case management model in breast cancer transitional care and to highlight methods for solving the common obstacles faced during the application of M-health nursing service.

We followed a four-step process: (a) Forming a cross-functional interdisciplinary development team containing two sub-teams, one for content development and the other for software development. (b) Applying self-management theory as the theoretical framework to develop the M-health application, using contextual analysis to gain a comprehensive understanding of the case management needs of oncology nursing specialists and the supportive care needs of out-of-hospital breast cancer patients. We validated the preliminary concepts of the framework and functionality of the M-health application through multiple interdisciplinary team discussions. (c) Adopting a multi-stage optimization strategy consisting of three progressive stages: screening, refining, and confirmation to develop and continually improve the WeChat mini-programs. (d) Following the user-centered principle throughout the development process and involving oncology nursing specialists and breast cancer patients at every stage.

Through a continuous, iterative development process and rigorous testing, we have developed patient-end and nurse-end program for breast cancer case management. The patient-end program contains four functional modules: “Information”, “Interaction”, “Management”, and “My”, while the nurse-end program includes three functional modules: “Consultation”, “Management”, and “My”. The patient-end program scored 78.75 on the System Usability Scale and showed a 100% task passing rate, indicating that the programs were easy to use.

Conclusions

Based on the contextual analysis, multi-stage optimization strategy, and interdisciplinary team work, a WeChat mini-program has been developed tailored to the requirements of the nurses and patients. This approach leverages the expertise of professionals from multiple disciplines to create effective and evidence-based solutions that can improve patient outcomes and quality of care.

Peer Review reports

Female breast cancer is the second leading cause of global cancer incidence in 2022, with an estimated 2.3 million new cases, representing 11.6% of all cancer cases [ 1 ]. Due to surgical trauma, side effects of drugs, fear of the recurrence or metastasis of breast cancer, changes in female characteristics, and lack of knowledge, patients with breast cancer frequently experience a series of physical and psychological health problems [ 2 , 3 , 4 , 5 , 6 ]. These health problems seriously affected patients’ life and work [ 7 , 8 ]. At present, community nursing in China is still in the developing stage, and the oncology specialty nursing service capacity of community nurses is not enough to deal with the health problems of breast cancer patients. It made continuous care for out-of-hospital breast cancer patients a weak link in the Chinese oncology nursing service system.

Nowadays, case management is employed to manage health problems for out-of-hospital breast cancer patients worldwide [ 9 , 10 , 11 , 12 , 13 , 14 , 15 ]. Case management involves regular telephone follow-ups and home visits by case management nurses to provide educational support to patients, thereby ensuring uninterrupted continuity of care [ 16 , 17 ]. The home visits and organization of patient information required for case management tasks consume a significant amount of time, manpower, and material resources [ 17 ]. In China, case management services are primarily undertaken by oncology nursing specialists from tertiary hospitals in their spare time [ 18 ]. However, the shortage of nurses has consistently been one of the major challenges facing the nursing industry in China, especially in tertiary hospitals [ 19 ]. Consequently, the implementation and promotion of case management in China also face great difficulties in reality [ 20 ].

The Global Observatory for eHealth (GOe) of the World Health Organization (WHO) defines mobile health (M-Health) as “medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices” [ 21 , 22 ]. With the development of digital technology and the COVID-19 pandemic in 2019, M-Health applications were further integrated into healthcare services, which increased the demand for M-Health applications in turn [ 23 , 24 ]. Compared with the traditional health service model, M-Health service model has the advantages of high-level informatization, fast response speed, freedom from time and location constraints, and resource-saving, etc. In the context of limited nursing human resources, M-Health service provides a new solution for the case management of out-of-hospital breast cancer patients [ 23 , 25 , 26 ].

Researchers have developed a range of M-Health applications targeting breast cancer patients. To our knowledge, none of these developed M-Health applications are designed for case management nursing services.

Early M-Health applications were mostly designed for single interventional goals, such as health education, medication compliance, self-monitoring, etc. Larsen et al. applied a M-Health application to monitor and adjust the dosage of oral chemotherapy drugs in breast cancer patients, and the results suggested that the treatment adherence was effectively improved [ 27 ]. Heo and his team successfully promoted self-breast-examination behavior in women under 30 years old using a M-Health application [ 28 ]. Mccarrol carried out a M-Health diet and exercise intervention in overweight breast cancer patients and found that the weight, BMI, and waist circumference of the intervention group decreased after one month [ 29 ]. Smith’s team found that their application promoted the adoption of healthy diet and exercise behaviors among breast cancer patients [ 30 ]. The application designed by Eden et al. enhanced the ability of breast cancer patients receiving chemotherapy to recognize adverse drug reactions [ 31 ]. Keohane and colleagues designed a health educational application based on the best practices and it proved effective in improving breast cancer-related knowledge [ 32 ]. The guideline-based M-Health application developed by Eden et al. optimized breast cancer patients’ individualized health decision-making regarding mammography [ 33 ].

With the progress of computer technology and the emphasis on physical and mental rehabilitation of breast cancer patients, some universities [ 34 , 35 ] in China have separately developed M-Health applications for comprehensive health management, which provide access to online communication, health education, and expert consultation.

Analyzing these developed applications deeply, three factors could be found that hindered the promotion of applications in real life. Firstly, the developing procedure usually lacks contextual analysis based on the actual usage context during the design phase. Secondly, there is a lack of consistent and long-term monitoring and operation staff in the subsequent program implementation. These factors may be the main reasons why many M-Health applications face difficulties in promotion and continuous operation after the research phase. Furthermore, as applications need to be installed on patients’ smartphones, certain hardware requirements, such as memory, may also pose restrict the adoption of M-Health applications to some extent.

In order to meet the needs of supportive care for out-of-hospital breast cancer patients and the needs of case management for oncology nurse specialists, we formed a multidisciplinary research team and collaboratively developed a WeChat mini-program for breast cancer case management in the CMBM (M-health for case management model in breast cancer transitional care) project. WeChat is chosen as the program development platform based on the following considerations. Firstly, WeChat is the most popular and widely used social software in China. As of December 31, 2020, the monthly active users of WeChat have exceeded 1.2 billion, and the daily active users of WeChat mini-programs exceeded 450 million [ 36 ]. Secondly, users can access and use the services of the mini-program directly within the WeChat platform, without the need to download or install additional mobile applications. This reduces the hardware requirements for software applications. The above two factors allow for a positive user experience and a realistic foundation for software promotion.

The purpose of this study is to describe the process of developing a tailored M-health component for the case management model in breast cancer transitional care and to highlight methods for solving the common obstacles faced during the application of M-health nursing service.

Methods and results

The development process was conducted in four steps: (a) An interdisciplinary development team was formed, consisting of two sub-teams dedicated to content and software development. (b) Using the self-management theory as the theoretical framework, contextual analysis was used to understand the case management needs of oncology nursing specialists and the supportive care needs of out-of-hospital breast cancer patients. Through iterative discussion within the interdisciplinary team, the preliminary conception of the application framework and function was formed. (c) A multi-stage optimization strategy was adopted to develop and regularly update the WeChat mini-programs, including three stages (screening, refining, and confirming). (d) During the entire development process, a user-centered principle was followed with the involvement of oncology nursing specialists and breast cancer patients, including development, testing, and iterative development phases.

The interdisciplinary team

An important prerequisite for developing M-health applications is the formation of an interdisciplinary development team. We built a multidisciplinary team consisting of researchers, oncology nursing specialists, and software developers. Each team member brought their expertise from their respective fields, and all individuals were considered members of the same team rather than separate participants with a common goal.

Two sub-teams were established, one responsible for content development, and the other for software development. The content development team consisted of researchers and six senior breast oncology nursing specialists with bachelor’s degrees and over 10 years of clinical experience. Their work included contextual analysis, functional framework design, and content review of the “Information” module. The software development team included researchers and experienced software developers. Their tasks involved developing the mini-program based on the functional framework and requirements designed by the content development team.

The development team used contextual analysis to identify the actual usage needs of two target groups for the mini-program: oncologist nurse specialists and out-of-hospital breast cancer patients.

Involvement of oncology nursing specialists and breast cancer patients following user-centered design principle

Since the oncology nursing specialists and breast cancer patients are targeted users of the mini-program, the two groups fully participated in the development according to the user-centered principle. Nursing specialists who in charge of case management were interviewed about the preliminary functional framework of the mini-program. The interview results are presented in the section “Driving the Development Process via the Contextual Analysis Findings.” Semi-structured in-depth interviews were conducted in the testing and iteration stage to gain user feedback from nursing specialists to improve the applicability and usability of the mini-program. The interview guide can be found in the supplementary material.

Breast cancer patients fully engaged in the three developing phases (Screening, Refining, and Confirming). In the Screening Phase, since the self-management theory was selected as the theoretical framework, the supportive care needs of out-of-hospital breast cancer patients were explored, and the functional framework of the mini-program was constructed accordingly. In the Refining Phase, patients were invited to evaluate the usability and practicality of the mini-program through system tests and semi-structured in-depth interviews. The results of the system test are presented in the Results of System Test section. The feedback from interviews and corresponding iterative updates are listed in Table  1 . In the Confirming Phase, our research team is conducting clinical trials in out-of-hospital breast cancer patients to find out the actual effect of the mini-program on recovery.

The theory framework of the mini-program

This study applied the self-management theory [ 37 ] as the theoretical framework. The self-management theory explains how individual factors and environmental factors influence an individual’s self-efficacy, which ultimately affects the generation and development of individual behaviors. Self-efficacy is influenced by direct experience, indirect learning, verbal persuasion, and psychological arousal. By providing individuals with sufficient knowledge, healthy beliefs, skills, and support, their self-efficacy is increased, and they are likely to engage in beneficial health behaviors and self-management. Individuals who are confident in their abilities to apply self-management behaviors and overcome obstacles by improving their self-management skills and persevere in their efforts to manage their health [ 37 ]. Self-efficacy is directly and linearly positively related to the active adoption of health management behaviors [ 38 ]. The functions of the various parts of the mini-program designed using self-management theory can broaden the pathways and levels of efficacy information generation in four ways: direct experience, indirect learning, verbal persuasion, and mental arousal. Patients with high self-efficacy will take positive steps to achieve desired goals and possess disease-adapted behaviors. The form of the mini-application function block diagram is shown in Fig.  1 .

Driving the development process via the contextual analysis findings

Contextual analysis [ 39 ] is a method of discerning the profound significance and influence of language, behavior, events, and so forth, by examining them within a particular environment or background. Rather than being an afterthought, contextual analysis sheds light on the meaning and inner dynamics of our primary subject of interest. Through contextual analysis, we can gain a deeper understanding of the user’s usage scenarios, including their motivations, goals, environment, and behavior. This helps us better understand user needs, as well as the problems and challenges they may encounter when using the software.

In this paper, we adopted contextual analysis to gain a detailed understanding of the needs of oncology nurse specialists and out-of-hospital breast cancer patients. The research team adopted a mixed research strategy to achieve contextual analysis of the target users. A cross-sectional study was conducted among 286 patients and qualitative semi-structured in-depth interviews were applied in 12 patients to find out the supportive care needs of out-of-hospital breast cancer patients. According to the contextual analysis results from patients, the functional framework of the mini-program was constructed. See Fig.  2 for details.

Supportive care needs of out-of-hospital breast cancer patients

Contextual analysis of breast cancer case management nurses was conducted through focus group interview. The interview results were listed as three themes: health information, personal self-management, and case management needs. Health information included breast cancer-related knowledge, the side effects of chemotherapy drugs, and symptom management measures. The key task of personal self-management contained temperature monitoring, weight management, functional exercise, and symptom management. Case management needs involved storage and management of patients’ medical records and development of a nurse-end program.

Based on the contextual analysis results of out-of-hospital breast cancer patients and the oncology case management nurses, the framework and functional block of the mini-program were formed. An overview of the CMBM Software development process is listed in Fig.  3 .

Overview of the CMBM software development process

Patient-end program functional modules

Using the results of the contextual analysis, we design the functional modules of the patient-end program based on the patient’s supportive care needs. For example, the “Information” section is designed to meet the “Information need” of breast cancer patients; the “social needs” and “spiritual needs” of patients suggest that breast cancer patients lack peer support, and for this reason, the"Interaction” section for patients has been added to the app to provide a communication platform for patients.

The patient-end program include four functional modules: “Information”, “Interaction”, “Management” and “My”. In the “Information” module, information about breast cancer treatment and health management are compiled based on clinical guildlines. The “Interaction” module allows patients to interact with fellow patients and consult an case management nurse. In the “Management” module, patients can record and review their self-management-related health status, including three medical parameters (temperature, blood pressure, weight) and three behavioral parameters (daily steps, medication, mindfulness excersice). The “My” module enables patients to input and edit their basic personal information and medical history. The main structure and information support module contents are listed in Fig.  4 .

The main menu of patient-end program

Nurse-end program functional modules

The design of the functional modules of the nurse-end program was also derived from the results of contextual analyses. The nurse-end program includes three functional modules: “Consultation”, “Management”, and “My”. The “Consultation” module is mainly used for online communication between case management nurses and patients. Nurses can enter the patient’s name in the search box to open a dialog box, and communicate with each other by sending text, voice and pictures. In the “Management” module, nurses can effortlessly search for patients by entering their name, WeChat nickname, or mobile phone number in the search box. This initiates a seamless dialogue, and with a simple click of the “+” button, patients can be promptly added to the “My Concerns” list. They can view the medical record information on its homepage, and add the postoperative treatment plan for the patient. The “self-management report” feature empowers nurses to stay up-to-date with patients’ recent well-being. By monitoring vital indicators like temperature, weight, and incidents of nausea or vomiting following chemotherapy, nurses can proactively ensure patients’ safety. The “clock in record” feature meticulously logs various patient activities including weight variations, exercise regimens, and medication adherence, providing a holistic view of their health journey. “Treatment monitoring Schedule” enables nurses to create customized chemotherapy schedules. With the first postoperative chemotherapy session scheduled in the calendar, the system seamlessly computes subsequent chemotherapy sessions and associated assessments. This transition to an online system marks a significant advancement from the traditional paper-based chemotherapy planning. Its automated scheduling and data tracking functions serve to alleviate the clinical nursing workload, enhancing efficiency and freeing up valuable time for focused patient care. The “My” module offers nurses the convenience of adding patients of interest or relevant content to their “My Favorites” section, enabling streamlined one-click access for viewing and management. The core structure and informational components of this module are outlined in Fig.  5 .

The main menu of nurse-end program

Driving the development process via the multi-stage optimization strategy

We adopted a multi-phase optimization strategy to drive the software development process. This strategy was proposed by Collins in 2005 and has become an important guiding theory for the development and evaluation of M-health interventions in recent years [ 40 ]. The strategy consists of three phases: Screening Phase, Refining Phase, and Confirming Phase. The Screening Phase need theories to identify and incorporate intervention elements. In this study, the initial version (1.0) development was based on self-management theory. Focusing on self-management, the results of contextual analysis, literature review and expert consultation were combined to design the mini-program version (1.0). The Refining Phase involves iterative adjustments to the previously version. In this study, the development team iteratively adjusted the mini-program version (1.0) according to users’ suggestions and test results. The Confirming Phase includes planning for clinical trials to test effect of the mini-program version (2.0) on self-management and recovery outcomes in out-of-hospital breast cancer patients.

Results of system test

Eight out-of-hospital breast cancer patients were recruited for system tests. The patient’s general information is listed in Table  2 .

The 10-item System Availability Scale (SUS)developed by Brooke was used [ 41 ]. The scale is a widely used method for quantitatively assessing user satisfaction with software systems. SUS is a Likert-5 and 10-item questionnaire (4 = strongly agree, 0 = strongly disagree), with Cronbach Alpha of 0.91. Generally, a system score above 60 on the SUS scale could be considered to be easy and simple to use, and the average score of SUS in our research is 78.75. The SUS scores of the mini-program system are presented in Fig.  6 .

System availability scale (SUS) score of patients

The research team designed the core task tests based on the typical and necessary self-management tasks of out-of-hospital patients. The core task of the “Information” module was listed as an example (Table  3 ). Functional tests include the passing rate for each task, and performance tests include the completion time of each task. More details can be found in Table  4 .

In this article, we demonstrated how to create a customized software solution for breast cancer case management practices based on a multi-stage optimization strategy, applied the contextual analysis method, and followed the user-centered principle. Preliminary test results showed satisfaction and acceptance of the WeChat mini-program among both out-of-hospital breast cancer patients and oncology nursing specialists.

Team effort

There were two typical patterns for developing M-health applications in the past. One was led by software developers, while the other was led by medical professionals. Each of these patterns has its own advantages and disadvantages. To overcome these shortcomings, some projects [ 42 ] developing M-health applications are now utilizing interdisciplinary team collaborations. This approach not only ensures the quality of the software but also makes sure that applications meet the actual needs.

In order to develop a customized software solution, our research team consisted of researchers, oncology nursing specialists, and software developers. The interdisciplinary team work dedicated to customizing software solutions together. Our team members each played to their strengths and held regular meetings to discuss and enhance our understanding and resolution of issues encountered during the software development process. Our team also included informal members: breast cancer patients, whose suggestions contributed to the practicality of the program.

Contextual analysis and user-centered design

Contextual analysis is a valuable tool that enables developers to design systems that are more relevant and user-friendly. And it allows us to understand any context-specific characteristics, practice patterns, and the openness of the target setting’s nurses and patients towards technology [ 42 ]. User-centered design can significantly reduce the cost of program iteration. More importantly, it has a profound influence on various aspects of a program including its design, functionality, information architecture, and interactive elements [ 43 ]. By analyzing different contexts, not only did we design features that better meet user needs, but we also predicted and addressed potential issues that users may encounter when using the mini-program in advance, thereby enhancing the user experience. In the iterative development stage, we discovered and improved some deficiencies in the design through core task testing and usability testing. Notably, the completion rate of the core task test reached 100%, indicating that our application is user-friendly and easy to operate.

• Multi-stage optimization strategy

In several priority areas of public health, researchers have successfully applied multi-stage optimization strategies to enhance their work, including software development and intervention programs [ 44 , 45 , 46 ]. In this study, we also apply this strategy to software development. While the multi-stage optimization strategy provides an optimization framework, it is important to note that our optimization objectives (such as software functionality and content requirements) are determined by key users involved in the research (out-of-hospital breast cancer patients and oncology nurse spescialists). This project adopts a multi-stage optimization strategy, iteratively improving the development of the mini-program through screening, refinement, and confirmation stages. Each stage aims to optimize our program.

The research team plans to explore the feasibility of mini program development program through preliminary experiment, and verify the intervention effect of mini program on self-management behavior, self-efficacy and quality of life and other indicators through formal experiment. A randomized controlled trial (IRB-2020-408) was initiated in August 2022 at a Class III hospital in Zhejiang, China, and is currently in the data collection phase.

There is no doubt that M-health will play a core role in the future of health care. However, to successfully implement and promote M-health applications in clinical setting, it is essential to analyze the needs of the target population. Additionally, it is crucial to determine who will be the driving force behind the implementation of the entire M-health project. This study demonstrates how to integrate M-health components into existing breast cancer case management care practices. In addition to providing a reference for other teams interested in developing and integrating M-health components into case management care models, this study also provides a reference for building M-health-featured care work models in practices.

In this study, the collaborative work of an interdisciplinary team with backgrounds in nursing and computer science, along with the active involvement of patients, not only facilitated the planning, developing, updating, and testing of M-health components based on the actual needs of the target population, but also increased the chances of acceptance and long-term implementation of the M-health program in practice.

This study demonstrates how to integrate M-health components into existing breast cancer case management practices. It provides insights for other reserch teams interested in developing and integrating M-health components into daily nursingt practice.

In the context of the digital age, M-health applications are rapidly becoming information sources and decision support tools for healthcare professionals and patients. However, it is crucial not to overlook the issues of information security and digital barriers for older adults.

Through interviews with outpatients with breast cancer and oncology nurses, we have gained insights into their concerns regarding information security. Some interviewees expressed concerns about information security and were worried about the risk of their personal information being leaked during app usage. Such concerns, to some extent, hinder the widespread adoption of M-health applications. Additionally, some interviewees mentioned that older patients, in general, find it challenging to learn and use the various functions of WeChat mini-programs, making it difficult to promote and apply M-health applications among the elderly population.

Solving these issues effectively is not only vital for the patients’ rights and interests but also crucial for the comprehensive implementation of M-health in practice. It is a matter that requires careful consideration in future development of M-health applications.

Data availability

The datasets generated and/or analysed during the current study are not publicly available but are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to express our sincere gratitude to all the breast cancer patients who participated in this research.

This study was supported by the Zhejiang Provincial Natural Science Foundation of China (LY18H160061) and Funding for innovation and entrepreneurship of high-level overseas students in Hangzhou.

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Hong Chengang, Wang Liping, Wang Shujin, Chen Chen, Yang Jiayue, Lu Jingjing, Hua Shujie, Wu Jieming, Yao Liyan, Zeng Ni, Chu Jinhui & Sun Jiaqi

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HCG conceived the entire paper framework and was responsible for writing the paper. WSJ and CC conducted all interviews and managed the mini-programs. YJY, LJJ and HSJ were responsible for the collection of clinical nurse data. CJH and SJQ were responsible for patient data collection. Data analysis was conducted by WJM, YLY and ZN. WLP was responsible for the revision, editing and approval of manuscripts. All authors have rigorously revised and edited successive drafts of the manuscript. All authors read and approved the final version of the manuscript.

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Correspondence to Wang Liping .

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The study was reviewed and approved by the Ethics Committee of ZheJiang Cancer Hospital (Ethic ID: ZJZLYY IRB-2020-408). All the participants signed written informed consent forms. This study was conducted in accordance with the 1964 Declaration of Helsinki guidelines.

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Chengang, H., Liping, W., Shujin, W. et al. Multi-stage optimization strategy based on contextual analysis to create M-health components for case management model in breast cancer transitional care: the CMBM study as an example. BMC Nurs 23 , 385 (2024). https://doi.org/10.1186/s12912-024-02049-x

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Election latest: Tories fall to worst rating since Truss in new poll - as Reform gain ground

It's a quiet day for the election campaign, owing to commemorations marking the 80th anniversary of D-Day. But new polls published today have brought no respite for the Tories, with one putting them at their lowest level since Liz Truss was PM - and with Reform breathing down their necks.

Thursday 6 June 2024 23:26, UK

• General Election 2024

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Election news

• Labour accuse Sunak of 'skipping' D-Day ceremony to 'convince people he's not a liar'
• Tories record worst rating since Truss in new poll
• Sunak under fire for taking more cash from race row donor
• Explained: Where do political parties get their funds?
• Minister defends exposing 'tender meat flippers' on train
• Scottish Tory candidate dropped for leader 'very saddened'
• Live reporting by Tim Baker and (earlier)  Ollie Cooper

Expert analysis

• Jon Craig: Dash for seats makes Tory duo look like self-serving elite
• Connor Gillies: Top Scottish Tory likely to face backstabbing claims

Election essentials

• Battle For No 10: PM and Starmer taking part in Sky News special
• Have your say: Be in the audience for our election leaders event
• Campaign Heritage: Memorable moments from elections gone by
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• Read more: Who is standing down? | Key seats to watch | How to register to vote | What counts as voter ID? | Check if your constituency is changing | Your essential guide to election lingo | Sky's election night plans

We're ending our live coverage for the night - but don't worry, we'll be back in the morning.

Before you go, here are the major announcements from the two big parties tonight.

Make sure to check back in the morning as the general election campaign rumbles on towards the end of another week.

Labour are going on the offensive after Rishi Sunak left the D-Day ceremonies in Normandy today early.

While the prime minister was present for the initial parts of the commemoration on the 80th anniversary of the landings, he was absent later on.

Defence Secretary Grant Shapps and Foreign Secretary Lord David Cameron took his place, with the latter pictured alongside leaders like Germany's Olaf Scholz, the US's Joe Biden and France's Emmanuel Macron.

Labour has also been keen to highlight a picture of Sir Keir Starmer alongside Ukraine's Volodymyr Zelenskyy.

A Labour Party source said: "If the prime minister has skipped this afternoon's D-Day commemorations to try and convince people he's not a liar, he should just tell the truth".

Jonathan Ashworth, Labour’s shadow paymaster general, said: "The prime minister skipping off early from D-Day commemorations to record a television interview where he once again lied through his teeth is both an embarrassment and a total dereliction of duty.

"Our country deserves so much better than out-of-touch, desperate Rishi Sunak and his chaotic Tory Party."

Meanwhile, Reform leader Nigel Farage said: "The prime minister has ducked out of the international D-Day event to fly back to the UK to campaign.

"I am here in Normandy in a personal capacity because I think it matters. Does he?"

The accusation that he was trying to defend himself against accusations of being a liar came after ITV News tweeted a clip of an interview with Mr Sunak.

Allegations that Mr Sunak was lying about the Labour Party wanting to raise tax by £2,000 were put to him.

The prime minister said this was "desperate" - and did not accept the claim was "dubious".

ITV's Paul Brand, who carried out the interview, later confirmed the chat took place after the PM came back from France - but ITV did not choose the time.

The £2,000 figure relates to alleged tax rises the Conservatives think Labour will put in place over the next four years - equating to £500 a year.

As Sky data and economics editor Ed Conway explained here - there are many flaws with the figure, and it ignores the fact the Conservatives have raised tax by £13,000 in the past five years if you use the same method.

It's just gone 10pm on what has been a reasonably quiet day on the election front - given the D-Day commemorations in Normandy - but there are still developments to bring you up to speed on. 

Notably, it's emerged the Conservative Party accepted fresh cash from donor Frank Hester days after the prime minister had condemned "racist and wrong" comments he made about Diane Abbott.

Here is what you may have missed:

• Labour said Rishi Sunak has "proven he is a man with no integrity" after accepting more money from Frank Hester;
• This includes a £5m donation in January, and another £150,000 in March , which came after the prime minister had condemned his comments about Labour's Diane Abbott;
• As a reminder, it was reported earlier this year that - in 2019 - he'd said Ms Abbott should be "shot" and made him "want to hate all black women" ;
• Lib Dem leader Sir Ed Davey has called on the PM to return the cash, while his party have pledged to introduce a cap on political donations;
• More polls are showing Reform catching up with the Conservatives;
• Labour has faced accusations it has U-turned on support for Waspi women who claim they are owed pension compensation;
• Elsewhere, Scottish Conservative leader Douglas Ross has officially announced his plans to stand at the general election;
• The move prompted Sky  chief political correspondent Jon Craig  to examine so-called "chicken run" Tory candidates;
• The Green Party  has pledged to spend £50bn a year more on the NHS through those with "broadest shoulders" paying more;
• The party also ditched a pledge made on its website to "reduce" childbirth interventions;
• In lighter news, veterans minister Johnny Mercer defended himself - and his "tender meat flippers" - after he was pictured barefoot on a train.

Sky News is also looking for people to be in the audience for its leaders' programme with Rishi Sunak and Sir Keir Starmer .

The Battle For Number 10 will air from 7pm next Wednesday.

Here are some other stories you might want to read:

Our essential political podcast,  Politics At Jack And Sam's ,  is going out every weekday through the election campaign to bring a short burst of everything you need to know about the day ahead as this election unfolds.

Listen to today's edition below… 

Tap here to follow Politics At Jack At Sam's wherever you get your podcasts .

The Sky News live poll tracker - collated and updated by our data and forensics team - aggregates various surveys to indicate how voters feel about the different political parties.

See the latest update below - and you can read more about the methodology behind the tracker  here .

Nadine Dorries, who was one of Boris Johnson's most loyal allies, has predicted the party is facing "annihilation" and might "disappear".

The former culture secretary has laid the blame at the feet of Rishi Sunak for not paying attention to Reform and UKIP and allowing them to take votes off the Conservatives.

Ms Dorries has been a prominent critic of Mr Sunak since she failed to get an honour on Mr Johnson's resignation list.

She was also asked about her opinions on allies of Mr Sunak - like party chairman Richard Holden - being given new seats to stand in .

Ms Dorries told the News Agents podcast it's "incredibly disgusting actually".

She said she and others were "reeling from the shock of it".

This morning we reported news that the Scottish Tory leader Douglas Ross would stand in a seat where the party's expected candidate is recovering from surgery.

Mr Ross had announced he was standing down as a Westminster MP to concentrate on his job as an MSP (Member of the Scottish Parliament) ahead of the 2026 Holyrood election campaign.

But with 24 hours left for nominations to be confirmed, he announced he will be standing in the new Aberdeenshire North and Moray East constituency.

The expected candidate, David Duguid, has just released a statement disputing claims from his own party that he was "unable to stand" due to his recovery.

'I am very saddened'

"This is simply incorrect," he said.

"Having been adopted by local members, I was very much looking forward to campaigning - albeit in a different format from normal. 

"It was not my decision not to stand."

He said the Scottish Conservatives made the decision without visiting him and without any "professional medical prognosis".

"Needless to say I am very saddened by the way this whole episode has unfolded, and it would be wrong of me to pretend otherwise," he added.

Our chief political correspondent Jon Craig has described the ordeal as "highly unusual" and said it "looks like a shabby stitch-up".

To close out tonight's Politics Hub With Sophy Ridge , her panel discussed whether manifestos make a difference to general elections.

These documents - which we expect to be start being published next week - contain the detailed set of policies each party wants to enact if it enters government.

Charlie Rowley , who was previously an advisor to Michael Gove, highlights the 2017 general election.

It was after the Conservatives and Theresa May published their manifesto that a row erupted over her social care plans - which contributed to the party losing significant ground in the polls.

He suggested that something "too bold" being in the Labour manifesto could see a similar change in electoral fortunes.

You can read more about Mrs May's manifesto woes in our Campaign Heritage post here .

Andy Street , who was until last month's shock election defeat the Tory mayor of the West Midlands, is speaking with  Sophy Ridge .

Seen as a totem of the centre ground in the Conservative Party, Mr Street lost his job to Labour by fewer than 2,000 votes.

He calls on Tories to try not to overly focus on Nigel Farage and the threat of his Reform party.

Instead, the Conservatives need to focus on the centre ground.

Tories shouldn't focus on 'core voters'

Mr Street points out how every major political change in the past 100 years has come from the middle.

Mr Street highlights Stanley Baldwin, Neville Chamberlain, Harold Macmillan, Margaret Thatcher, Tony Blair and David Cameron as examples.

Pursuing the party's "core voters" - like pensioners and the wealthy - will see the Tories "cede the middle ground".

He says his message to the party is that "the real battle is with Labour and the Lib Dems over the middle ground".

"We're all obsessed with what Nigel Farage is doing at the moment - but that is just one flank," he says.

"The real debate is in the centre."

 Controversy around political donations has erupted again today after it emerged the Tories had received yet more money from their top donor Frank Hester.

That's despite him having made comments about Labour's Diane Abbott that the prime minister said were "racist and wrong".

It prompted our  deputy political editor Sam Coates to dive into the numbers - many of them strikingly large - behind how our political parties get their money...

Perhaps the most noteworthy moment on the campaign trail today was news that the Scottish Tory leader Douglas Ross would stand in a seat where the party's expected candidate is recovering from surgery.

But this morning, with 24 hours left for nominations to be confirmed, he announced he will be standing to be a Westminster MP in the new Aberdeenshire North and Moray East constituency.

The expected candidate, David Duguid, had said he'd been recovering well from his op and was looking forward to standing.

You can read more on the controversy from our political reporter Alix Culbertson :

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