Thromboembolism is a common complication of heart disease – particularly in patients with atrial fibrillation (AF). Decisions to prescribe an anticoagulant are based on assessment of an individual patient's risk of clotting and the side-effects of treatment. With growing numbers of patients with heart disease, the number of patients on anticoagulants is increasing and there is a shift to primary care-based anticoagulation clinics. Practice nurses have a central role in educating patients about anticoagulation therapy and in monitoring their ongoing care.
Over half of all adults in the UK are overweight, according to latest figures. The number of people who are obese has tripled over the last 20 years, and is still rising. But is weight management an issue for primary healthcare teams? There is clear evidence that it is – with obesity being directly related to increased risk of death and a range of chronic diseases. Obesity reduces life expectancy, on average, by nine years.
At long last there is some encouragement for general practices to optimise detection and management of obesity. The new General Medical Services (GMS) contract includes 208 from a total of 1050 points available in the Quality and Outcomes Framework that are affected by weight loss, offering a major financial incentive to general practices to encourage patients to lose weight.
Foot complications are very common in patients with diabetes. At least one in six diabetics develop foot ulcers at some point in their lives. This article reviews why foot complications occur in diabetes, how you can detect foot problems early, and treatment and prevention strategies. The National Service Framework for Diabetes suggests that targeted foot care for people at high risk could save hundreds of amputations a year. By detecting complications earlier, we can make a real difference to patients' lives, reducing morbidity, improving quality of life and even saving limbs.
The number of people who smoke has fallen over the past 30 years under a barrage of tobacco control measures, including increasing the price of cigarettes, advertising bans, and health education campaigns. But, one in four premature deaths in the UK (adults aged 35–65 years) are still caused by smoking, and a study published recently warned that today's smokers puff their way through more cigarettes and start at an earlier age than smokers of fifty years ago. This means that, on average, men who smoke now die ten years earlier than men who don't smoke.
Can primary care make an impact on this ongoing problem? The good news is yes – and the new GMS contract is finally offering us incentives to include smoking in our health promotion activities. In this article, we give you the ammunition to put smoking cessation on your agenda – with the health and economic reasons why it makes sense to help patients quit. Practice nurse Rosemary Evans then explains how she does it in her Docklands practice.
Beta blockers are well established drugs in the treatment of cardiovascular disease, after first being introduced 20 years ago. Today, they are used to treat patients with a range of cardiovascular conditions – hypertension, myocardial infarction, angina, heart failure and abnormal heart rhythms (arrhythmias). There is good evidence for beneficial effects with beta blockers and their use is recommended in many guidelines, including the recent British Hypertension Society guidelines. Prescribing of beta blockers in patients with heart disease is further encouraged as a 'quality marker' in the new GMS contract.
Primary care nurses play a central role in the management of type 2 diabetes in the community. This includes helping patients to use their drug treatment correctly. Although many patients with type 2 diabetes initially respond well to weight loss and exercise, most require oral hypoglycaemics and half of all patients eventually require insulin to control their glucose levels in order to prevent the devastating long-term complications of inadequately controlled diabetes. Linda Goldie gives an up-to-date review of the newer insulins – including the insulin analogues, insulin lispro, insulin aspart and insulin glargine – that have been introduced.
There is good evidence that tight glycaemic control significantly improves outcomes in patients with type 2 diabetes. All practice nurses will be looking to achieve the new General Medical Services contract (GMS2) targets for HbA1c reduction in diabetes (see box). Practices will be developing prescribing strategies to achieve this reduction, in accordance with good clinical practice. Metformin offers an important first-line therapy for type 2 diabetes. The introduction of a new, sustained-release formulation – Glucophage SR – should improve patient compliance with metformin and so improve glycaemic control.
There is no doubt about it, achieving and maintaining weight loss long term is a great challenge. Primary care nurses have a significant role in motivating patients to adopt a healthy lifestyle and to persevere with weight management programmes. In the last issue of BJPCN we looked at how to raise the tricky subject of obesity with patients. This time, we continue the issue by exploring how practice nurses ensure a positive working relationship with their patients with weight problems and encourage them as they tackle the long-term issue of obesity.
Renal disease is common and is increasing in prevalence as the main risk factor for impaired kidney function – diabetes – affects more people. Approximately 30% of patients with type 2 diabetes develop some degree of nephropathy, with some ethnic groups at even higher risk. Diabetes is now the largest single cause of end-stage renal disease in the UK, accounting for 30–40% of all cases. The very early stages are asymptomatic and the disease process develops slowly over 15–20 years, so early screening and prevention strategies are paramount in reducing the burden of renal failure. Primary care nurses are well placed to play a pivotal role in this process.
More and more is being expected of practices in improving the management of diabetes – with initiatives such as the National Service Framework (NSF) for Diabetes and NICE guidance setting increasingly ambitious targets. The National Diabetes Support Team (NDST) has been set up to help support local services throughout the NHS and in meeting these challenges. In this issue, they share latest advice for practices and patients on disposing of used syringes and other sharps.