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1. Provide a short description of the condition this patient has been diagnosed with.

John is 18 years old and was diagnosed with asthma at the age of 3 years after having a
severe chest infection and was prescribed preventer and reliever inhalers.
Asthma is a chronic disease of the bronchial tubes in the lungs that leads to narrowed
airways. It typically develops in childhood, and is characterised by wheezing,
breathlessness, chest tightness and coughing (Gibson et al. 2013; Luyster et al. 2012).
Asthma is recognized as a highly prevalent health problem affecting an estimated 300
million people of all ages, ethnic groups, and geographic origins, with an additional 100
million people estimated to be affected by 2025 (Masoli et al. 2004). Johns asthma is
proving to be rather difficult for him now especially since he has moved out of his parents’
home to live on his own for uni.

2. Discuss how the condition is affecting the psychological state of the patient.

From the case study it is clear that John’s psychological state is being affected as he is
finding looking after himself quite difficult and is worried and anxious about his exams. He is
embarrassed in front of his friends which is causing him to become socially isolated making
him feel rather down and depressed. Literature has suggested that depressive symptoms
are more common in asthma patients than in the general population and perhaps even
more common than in some other general medical conditions (Zielinski, 2000). Seigel et al.
1990, found that adolescents with asthma had significantly higher Beck Depression
Inventory (BDI) scores than did normal healthy age-matched controls. Moreover, a cross-
sectional study involving 78 patients with controlled or uncontrolled asthma was carried out
by Vieira et al. 2011 and it was found that the prevalence of anxiety and depression was
significantly higher among patients with uncontrolled asthma than among those with
controlled asthma.
The sample within Seigel’s study consisted of individuals who had been defined as severely
ill and had been hospitalised at least twice in the prior year, showing a very high level of
severity or poor ability to control their condition, which may not be able to be generalised
to John as much as his asthma does not seem that severe, however it is clear from the case
study that John is not able to control his asthma very well and did require medical
treatment after his most recent asthma attack . Similarly, Vieria et als carried out a cross-
sectional study involving 78 patients over the age of 18 and found that levels of anxiety and
depression were higher in patients who were not able to control their asthma well, which is
what seems to be the case with John. The present study however has the intrinsic
limitations of a cross-sectional observational study. Therefore, it is impossible to determine
whether anxiety was the cause or the consequence of uncontrolled asthma. Furthermore,
the aforementioned study is supported in a study by Marco et al. 2010 who found that
patients with poorly controlled asthma were more frequently diagnosed with anxiety and
depression compared to those with better controlled asthma. This study however may lack
ecological validity as the patients included were enrolled from tertiary asthma clinics
meaning they were receiving specialist care. John felt extremely embarrassed after his last
attack in front of his friends, and now does not want to go out with them, showing that it is
likely that he has developed social anxiety. Overall it is clear to see that Johns psychological
state is being affected negatively, which in turn one can assume it will also have a negative
effect on his quality of life.

3. Discuss the impact this condition is having on the quality of life of the patient.

From the case study it is clear that Johns quality of life is being affected negatively in more
than one way. Johns sleep is being affected as he is having trouble sleeping most days due
to feeling wheezy. He is also being held back from carrying out some forms of physical
exercise and leisure as his breathing is getting in the way of his ability to play rugby. His
education is also being affected as exams are making him worry a lot and making him rather
anxious. He is also really stressed out and does not know how to cope. Lastly his social
interactions are being affected as he has developed social anxiety causing him to isolate
from his social group. A cross sectional study by Gandhi et al 2013 looked at asthmatic
children aged 8-17 years and found that children with better asthma control reported
higher levels of health-related quality of life (HRQoL) compared to those with lower levels of
asthma control. Furthermore, Sundell et al. 2010 found that poor adherence to asthma
treatment has a negative impact on HRQoL. The study by Gandhi et al. included children
aged 8-17 years who are younger than John, however it does include adolescents whom are
not very far of Johns age so can be related to John. An important limitation to consider with
this study is that the cross-sectional design limits the studies ability to interpret the casual
relationships amongst these variables. Therefore, we are not able to say whether better
asthma control results in better HRQoL, or if a better HRQoL results in better asthma
control. There have however been other studies to support this relationship between
asthma and low HRQoL. Gonzalez-Barcala et al 2012 carried out a cross sectional study on
adults and found a considerable detrimental effect on asthmatics HRQoL, but we once again
are not able to interpret the casual relationship between the two variables.
More specifically in relation to asthma and sleep, a survey study conducted in 1988 of 7,729
asthmatics found 74% of these patients awoke once a week with asthma symptoms. In the
same study, 40% of the subjects actually reported symptoms every night (Turner-Warwick,
1998). This study shows that individuals with asthma are a lot more likely to have troubles
with their sleep, affecting their quality of life. From this study however, it is not known how
severe the condition of the participants, as we may assume the worse the state of their
condition the more likely they are to have disruptions with their sleep. As James is living
away from home, it is likely that sooner or later he will need to get a job to help support his
living costs. This decrease in quality of life is likely to affect his ability to get or maintain a
job without any difficulties.
4. Discuss the difficulties the patient is having coping with their condition.

From the case study it is clear to see that John is having difficulties controlling his asthma
when he carries out sports activities and when out and about in social environments and in
his last attack he forgot to take his inhaler with him. Studies such as one carried out by
Crock et al 2009, which involved a survey of 1,485 children under the age of 18 have shown
that Inappropriate adherence to both preventer and reliever inhalers have been reported as
a major contributor to uncontrolled asthma in inner-city populations (Crocker et al 2009).
A qualitative analysis by Simoni et al 2017, was carried out to explore the barriers of inhaled
asthma treatment in adolescents aged 16 to 19 with asthma and it was found that
adolescents described concerns relating to social stigma resulting in ‘embarrassment of
taking inhalers’. The asthma diagnosis and the associated need to take inhaler treatment in
public had important consequences on adolescents’ social life. This could lead to derision
(even from ‘friends’) and social exclusion, for example, for not taking part in social activities
like drinking and clubbing. This present study used an online forum to gather data meaning
the spontaneous nature of the data provided are less likely to be affected by self-
presentation giving accurate accounts. The study carried out by Crocker et al, looks at
children under the age of 18, and although John is older it is clear from the case study that
John is not using his inhalers appropriately either, as reported in the study. When John was
living at home, his mum was always reminding him to take his preventer inhaler which
meant his asthma was well controlled, however without his mum being there to remind him
it is likely that he forgets often resulting in less well controlled asthma. Moreover, one could
assume that John would try his best to refrain from using his inhaler in public especially in
front of his friends due to embarrassment.

5. What interventions would you recommend to help the patient manage their condition
more effectively?

From the case study, it Is clear to see that John would benefit from interventions to help
him manage his condition more effectively including to be able to self-administer his
inhalers when needed and to be able to cope with any attacks out in public.
Healthcare professionals have a responsibility to ensure that asthmatics get personalised
advice to enable them to optimise how they self-manage their condition (Pinnock, 2015).
This self-management education should be reinforced by a written personalised asthma
action plan which provides a summary of the regular management strategy, how to
recognise deterioration and the action to take. A review by Gibson et al 2002 looked at 36
randomised trials involving 6090 participants over the age of 16 and compared self-
management education which included the provision of a written action plan for self-
management of exacerbations together with self-monitoring and regular medical reviews
with usual care in adults. He found that this use of an action plan almost halved the risk of
hospitalisation in half. This may be of benefit to John, allowing him to self-monitor himself
and remember to take his inhalers when needed, as he has now moved out and doesn’t
have his mum to remind him. Additionally, it may prove quite useful in instances such as his
asthma attack which occurred whilst around friends who smoke and may help him
understand how to deal with it better and avoid panicking as much, giving him a greater
sense of control. This in turn may cause him to be less embarrassed if an attack were to
occur again in front of his friends or whilst outdoors. Although the self-management
education plan seems like a good intervention, there is evidence that implementation of the
plan is patchy. Roberts et al 2012 found that 76% of respondents discussed asthma self-
management with patients; however only 47.8% of patients received a written action plan.
Barriers to implementation included patient factors (compliance, literacy and patient
understanding), time constraints and insufficient resources. This shows that the
interventions ability to be effective rests not only on the patient but with the healthcare
professional too.

A slightly more extreme intervention which John could consider is an individualised asthma
programme which is directed at behavioural change in asthmatic patients who reported
complaints and impairments. Put et al 2003, carried out a study in which mild-to-moderate
asthma patients aged 10 to 65 years were randomly assigned to a programme or waiting list
condition. Both groups were evaluated at three consecutive moments, each separated by 3
months. It was found that compared with the controls, the programme group reported less
symptoms (obstruction, fatigue), better quality of life (activity, symptoms, emotions),
decreased negative affectivity, and increased adherence, immediately after finishing the
programme and at 3 months follow-up. All three cognitive variables (knowledge, attitude
towards asthma, self-efficacy) improved in the programme group but not in the waiting list
group. If John was willing to commit to the programme, he could use this intervention to
help him cope with his symptoms, increase his quality of life, as we had previously
mentioned that it had been affected negatively and reduce any feelings of depression and
anxiety. A major limitation of this study was that only results at 3 months follow-up were
reported, so the long-term effects of this intervention are not known in this study. However,
a study by Lahdensuo et al 1996, found self-management efficient even when followed up
12 months after giving evidence to a longer lasting effect.