Must Complete: Yes
Word Length: 1500 words
Notes: Written assessment
This assessment relates to:
Learning Outcomes: 1, 4, 5, 6
Nursing managment of chronic conditions
Using the case study in Module one; Mathew Thornton to address the task below
Task:
Outline what strategies and assessments you as a Registered Nurse would provide as part of your care for Mathew Thornton. Ensure you include holistic, person-centred and culturally appropriate care. Reflect on how these strategies and assessments would facilitate optimum health outcome and relate to the National Strategic Framework for Mathew.
Contents for assignment
Topic 1
Meet Mathew – 33, 180kg
Mathew lives alone on a small farm holding outside of Farmdale. His father is James Thornton (who you met in HSNS270) and his mother is Melinda, who is 70 years old. Melinda was born in Farmdale and is an elder in the Aboriginal community. Mathew also identifies as being of Aboriginal descent. Mathew has two sisters, Rebecca who is currently living with their parents after separating from her husband due to domestic violence. She has 3 boys, Paul (10), Steven (6) and Peter (4). Mathew feels that his life is at risk. Mathew has vowed to lose weight as he now has type two diabetes and he is frightened of losing a limb or ending up on dialysis, but instead he turned to food as support and put on more weight. Mathew's nieces and nephew are his greatest joy – he takes them on trips but gets frustrated with his limited mobility. At his other sisters found he is distressed by walking in the paddocks. He has to stop every four or five steps due to being so obese and physically restricted. His back aches under the pressure of the weight around his stomach and his legs swell up.
What are the risk factors for chronic conditions?
A diverse range of factors influence the health and well-being of the Australian population. These factors are attributes, characteristics or exposures that increase the likelihood of a person developing a disease or health disorder. They can be categorized as follows:
• Behavioral risk factors
• Biomedical risk factors
• Non-modifiable risk factors
• Physical environment determinate s
• Social and economic determinants
Using the case study above provide an example of each of the risk factors
Type of Risk factor Define Provide an example of how this could relate to Mathew
Behavioral risk factors Mathew lives in a rural area and alone he does not like to cook and relies on the local take away shop where he gets hot chips for morning and afternoon tea as well as eating a large breakfast of bacon and eggs and white bread, meat pies for lunch and ham-burgers and chips again for dinner he like to drink at least 3 liters of coke a day. Mathew also does no exercise .
Biomedical risk factors
Non-modifiable risk factors
Physical environment determinate's These comprise both the natural and built environment, can impact health in a subtle or obvious manner and can occur over the short or long-term.
Social and economic determinants
Topic 2
Topic 2: Framework for Chronic Care Management
? Previous: 1. Frameworks for Chronic Care ManagementNext: 3. Models of Care ?
2. Mathew Thornton
Mathew
Mathew is a 33 year old Aborginal gentleman with a history of obesity, diabetes type 2 and hypertension. He is seeking treatment in an out-patient clinic at Farmdale Community health center with the local dietitian. The local dietitian suggest that he sees his local GP to get a referral to a specialist endocrinologist for medical weight loss management. he is well aware of the link between obesity, diabetes and cardiovascular disease and felt this appointment could be his last chance in getting help with his health problems to lose weight. As a child Mathew had been normal weight, during adolescent he played rugby for his local club and ended up in a prop position on the field (The props -prop up- the hooker in the scrum. They form part of the front row of the scrum and push against the opposition's props). He gradually put on weight and was overweight in his early twenties. The football culture which he loved was fun and he drank a lot of beer and ate a lot of meat pies at the football field after the games.
Mathew developed diabetes type 2 and hypertension in his early thirties (two years ago) and is medicated with anti-hypertensive and anti-diabetics. His GP (primary care physician) had not really been interested in his weight and instead suggested higher doses of medications or insulin injections on multiple occasions. Mathew was not interested in insulin injections as he was afraid of gaining more weight.
Mathew has now been sedentary for the last 5 years and has also had to give up work as a local farm hand on his sisters property out of town. He had tried many weight loss efforts and his diet had been high in fat and calories although he was very well educated in nutritious food. However, he has admitted to overeating, and periods of binging. He drinks about 3 liters of coke a day and has at least three service of hot chips per day.
Mathew is refereed to a weight management clinic in a metropolitan tertiary hospital 600km form Farmdale .
His initial anthropometric measurements included a weight of 180kg with a height of 1.81m, a body mass index (BMI) of 54.94kg/m2 which classified him as morbidly obese. His fat % was 52.2% with 85 kg fat mass measured by bioelectrical impedance analysis (BIA) (Tanita Body Composition Analyzer BC-418) for analyzing the composition of the body, such as weight, lean body mass (LBM), total body water(TBW), fat free mass (FFM) and basal metabolic rate (BMR). Her HbA1c had the last 2 months ranged from 11.7% till 8.8% and his hypertension was 160/95 mm Hg.
3. Models of Care
The Chronic Care Model
The Chronic Care Model developed by Wagner, Austin, Davies et al (2001) is effective in the management of many chronic conditions in improving both clinical and behavioral modifications. The Wagner Chronic Care Model places emphasis on enhancing health care professionals’ skills in support by promoting individuals with chronic conditions ensuring they are informed and engaged. This model identifies six essential elements required by the healthcare system to deliver high-quality chronic health care. These elements consist of:
1. Health system
2. Community
3. Self-management support
4. Delivery system design
5. Decision support
6. Clinical information systems
These six core elements assist in forming partnerships between Health care professional and an individuals, families and carers to ensure they are informed and are able to participate actively in their care. This model can be adapted and applied to numerous chronic conditions, health care settings and target populations (Wagner, Austin, Davis, Hindmarsh, Schaefer, & Bonomi., 2001).
Topic 3: Implementing Care in Chronic Conditions
? Previous: 1. Care Management in Chronic ConditionsNext: 3. Models of Self-managment ?
2. Mathew Thornton
Mathew
Mathew is a 33 year old gentleman with a history of obesity, diabetes type 2 and hypertension.
Weight management clinic - Intervention
It was suggested that Mathew attempt a weight loss of 5-10% to assist him to manage his diabetes with diet rather than medication. On attending he appeared motivated and had a positive approach to losing weight. He felt the time was right for him, and he was keen to manage his diabetes on diet alone. Following assessment the specialist addressed Mathew's weight management issues in an emphatic manner. Through changes in his eating pattern (smaller portions) and increased activity he could lose weight.
Mathew was refereed to the community nurse at Farmdale to commence his weight loss and it was suggested he attends a lifestyle modification program. Sustainable lifestyle modification strategies are needed to address obesity and cardiovascular risk factors. Intensive, individualised programs have been successful, but are limited by time and resources. The community nurse was asked to formulate a group-based lifestyle education program based upon national diet and physical activity (PA) recommendations to manage obesity and cardio-metabolic risk factors for the community.
The community nurse begins to develop a lifestyle modification program using the self management framework. Prior to Mathew being enrolled in the program the Registered community nurse assess Mathew including his readiness for change.
Mathew's readiness assessment for change
The Transtheoretical Model describes the stages of behavior prior to change. It focuses on the individual’s decision making. This model involves the state of feeling, awareness, judgments, perceptions, and behavior. This model has been used in a variety of problem behaviors.The Transtheoretical Model describes the process of change in 5 stages.

Date: Readiness assessment for change
Name:
Assessment
Precontemplation The person has no intention to change or take action within the near future. In this stage, people are usually uninformed about the consequences of their behavior or they may have failed at previous attempts to change. They may avoid seeking information that would help them change their behavior.
Contemplation The person intends to change within the next 6 months. He/she is aware of both the positive effects and the negative effects of change. This can cause uncertainty as to which approach to follow and result in procrastination and the inability to make a move to change. This person is not ready for an action program.
Preparation The person plans to take action within the next month. He/she has usually prepared and has a plan of action. A program of action that would assist with behavior change would be beneficial. Examples of helpful programs may be in smoking cessation, weight loss or an exercise program.
Action The person has made significant modifications in his/her behavior and way of life.
Maintenance The person is not working as hard as the person in the Action mode, but is working to prevent a relapse. The person is confident of continuing to change.
Plan
Registered Nurse signature
Adapted from: Prochaska JO. Stages of change and the transtheoretical model. 1985.
Complete Mathew readiness for change assessment and think about how you may develop your own lifestyle goal and which state of change you are currently in.
Topic 3: Implementing Care in Chronic Conditions
? Previous: 2. Mathew ThorntonNext: 4. Enquiry Resources and Readings ?
3. Models of Self-managment
Chronic Disease Self-Management
Approaches to managing chronic illness have changed from traditional provider–patient relationship to a paradigm where individuals with chronic conditions guide their own care, in partnership with health care providers. In chronic conditions their are generally common patient-centric strategies to deal with the disease and the challenges it poses. Regardless of the chronic condition, their are a generic set of skills that individuals must acquire to manage their illness and improve health outcomes.
Principles of Self-management
To support individuals, families and carers to be able to self-manage their own chronic condition, Lorig’s and Holman (2003 identified six principles of self-management behaviours that a person must develop, these include:
1. Problem solving,
2. Decision making,
3. Resource utilisation,
4. Forming of a relationship with a provider
5. Taking action.
6. Self-tailoring
(Lorig, & Holman, 2003).
Below watch the you tube clip from the National Nursing Institute of research (NNIR). This lecture was given by Dr kate Lorig in 2017 and is titled -Chronic Disease Self-Management—Evidence, Instruments, Translation, and Beyond,” Dr. Lorig discusses the effectiveness of low cost self-management interventions for reducing symptoms and improving quality of life. She also explored the role of self-efficacy as a predictor and moderator of outcomes.

Image 1: The Chronic Care Model was developed by Ed Wagner, and is often known as the ‘Wagner Model’. (image above).
Thinking about the case study of Mathew how would you apply each element to him. Below is table that you can use to guide your response
1. Health System: Create a culture, organisation and mechanisms that promote safe, high quality care
2. The Community: Mobilise community resources to meet needs of patients
3. Self-Management Support: Empower and prepare patients to manage their health and health care
4. Decision Support: Promote clinical care that is consistent with scientific evidence and patient preferences
5. Delivery System Design: Assure the delivery of effective, efficient clinical care and self-management support.
6. Clinical Information Systems: Organise patient and population data to facilitate efficient and effective care
The world health organisation (WHO), together with the McColl institute, adapted the chronic care model developing the Innovative Care for Chronic Conditions Framework a comprehensive conceptual framework for the prevention and management of chronic conditions. The Innovative Care for Chronic Conditions (ICCC) Framework provides greater emphasis to community and policy aspects of improving health care for chronic disease. The Innovative Care for Chronic Conditions Framework is centered around the idea that optimal outcomes occur when a health care triad is formed. This triad is a partnership among patients and families, health care teams, and community supporters. Micro-, meso-, and macro-levels provide a reasonable framework and refer to the patient interaction level, the health care organization and community level, and the policy level, respectively. Each of these levels interacts with and dynamically influences the other two.