208
Unit 3
Applying concepts from the nursing process
•
Normalising individual and family life as much as possible
•
Living with altered time, social isolation and loneliness
•
Establishing the networks of support and resources that
can enhance quality of life
•
Returning to a satisfactory way of life after an acute
debilitating episode (e.g. another myocardial infarction or
stroke) or reactivation of a chronic condition
•
Dying with dignity and comfort.
Phases of chronic illness
Chronic conditions can pass through different phases, as
described in Table 10-2. However, this course may be too
uncertain to predict with any degree of accuracy. The course of
an illness can be thought of as a trajectory that can be managed
or shaped over time, to some extent, through proper illness
management strategies (Lubkin & Larsen, 2013). Although
coping and adaptation are critical to all phases of chronic ill
health, it is important to keep in mind that not all phases occur
in all patients; some phases do not occur at all, and some phases
may recur. Each phase is characterised by different medical and
psychosocial issues. For example, the needs of a patient with a
stroke who is a good candidate for rehabilitation are very differ
ent from those of a patient with terminal cancer. By thinking in
terms of phases and individual patients within a phase, nurses
can target their care more specifically to each person. Not every
chronic condition is necessarily life-threatening, and not every
patient passes through each possible phase of a chronic condi
tion in the same order. Using the trajectory model enables the
nurse to put the present situation into the context of what might
have happened to the patient in the past; that is, the life factors
and understandings that might have contributed to the present
state of the illness. In this way, the nurse can more readily
address the underlying issues and problems.
members of minority groups, especially Indigenous people,
are poor, or are younger than 25 years of age
• Report that they do not receive adequate information and
counselling about self-care from their doctor, including
information about medication therapy needed to avoid
complications
• Report being confused about self-care activities even if
they receive counselling about self-care from their doctor
• Report that treatment options and their pros and cons are
not discussed with them by their doctor
• Report that their preferences regarding treatment are not
taken into account and they do not feel that their doctor
collaborates with them about management of their illness
• Do not feel fully involved in decisions about their own care
and do not feel a sense of confidence about managing their
illness
• Report that they were never advised or are confused about
how to manage their illness
• Report having little sense of control over their lives and their
illness
• Report infrequently receiving information or
recommendations from their doctor about healthy
behaviours (e.g., exercise, weight control, smoking
avoidance, misuse of alcohol, healthy eating)
ASSESSMENT
Characteristics of patients with chronic illness
People with chronic illnesses characteristically:
• Experience greater gaps in economic and cultural access to
the healthcare system than those without chronic illness
• Report having increasing difficulty affording healthcare
• Have high rates of unmet needs for support services,
including home care and transportation, rehabilitation
services, referral, and counselling
• Lack financial access to healthcare and to insurance
coverage and affordability, as well as physical access
• Report poorer quality of life, fewer visits to healthcare
providers, less knowledge about how to manage their
illness, poorer relationships with their doctors, and less
complete benefit from modern standards of care if they are
uninsured or underinsured when compared with those who
have adequate insurance
• Do not receive the information and services needed to
manage their illness successfully
• Are infrequently advised by their doctors to make healthy
behaviour choices
• Do not receive recommended condition-specific tests and
treatments about one-half of the time
• Are at high risk for having unmet health-related needs
• Are less likely to receive appropriate levels of care,
information, and attention from their doctors if they are
CHART
10-1
Adapted from Robert Wood Johnson Foundation. (2001). A portrait of the chronically ill in America, 2001. Report from the Robert Wood
Johnson Foundation National Strategic Indicator Survey. Princeton, NJ: Robert Wood Johnson Foundation.
Table 10-2 Phases in the Trajectory Model of
Chronic Illness
•
Pretrajectory:
Genetic factors or lifestyle behaviours that place an
individual or community at risk for the development of a chronic
condition
•
Trajectory onset:
Appearance of noticeable symptoms; includes period
of diagnostic investigation and announcement of diagnosis; may be
accompanied by biographic limbo as patient begins to discover and
cope with implications of diagnosis
•
Stable:
Illness course and symptoms are under control; biography and
everyday life activities are being managed within limitations of illness;
illness management centred in the home
•
Unstable:
Period of inability to keep symptoms under control or
reactivation of illness; biographic disruption and difficulty in carrying
out everyday life activities; adjustments being made in regime, with
care usually taking place at home
•
Acute:
Severe and unrelieved symptoms or the development of illness
complications necessitating hospitalisation or bed rest to bring illness
course under control; biography and everyday life activities temporarily
placed on hold or drastically cut back
•
Crisis:
Critical or life-threatening situation requiring emergency
treatment or care; biography and everyday life activities suspended
until the crisis passes
•
Comeback:
Gradual return to an acceptable way of life within limits
imposed by disability or illness; involves physical healing, stretching
limitations through rehabilitative procedures, psychosocial coming to
terms, and biographic reengagement with adjustments in everyday life
activities
•
Downward:
Illness course characterised by rapid or gradual physical
decline accompanied by increasing disability or difficulty in controlling
symptoms; requires biographic adjustment and alterations in everyday
life activities with each major downward step
•
Dying:
Final days or weeks before death; characterised by gradual or
rapid shutting down of body processes, biographic disengagement and
closure, and relinquishment of everyday life interests and activities
