Chapter 10
Chronic illness, disability and rehabilitation
209
CLINICAL REASONING CHALLENGE
A 28-year-old woman with three children younger than
4 years of age has recently been diagnosed with multiple
sclerosis (MS) following vision loss secondary to optic
neuritis. Her neurologist has recommended that she begin
injection therapy with one of the illness-modifying agents
to minimise the number and severity of MS exacerbations.
She is very active in her community through the church
and playgroup. She states she cannot fit learning about MS
or injection therapy into her very busy life. Further, she
states she doubts the diagnosis is correct, but is not inter
ested in seeking a second opinion or in talking to anyone
knowledgeable about MS. Identify approaches you would
use to establish a plan of care with her. Link your teaching
to the trajectory onset phase of chronic illness. How would
your plan of nursing care change in the acute and crisis
stages of chronic illness?
Nursing management
Doctors prescribe therapies, such as medications and diet, and
give directions for how much, when and how they are to be
used. It is important to work individually with each person
and family to identify the best ways to integrate their treat
ment regimens into their daily living activities, because each
person is an individual. People with chronic illnesses often
report receiving inadequate care, information, services and
counselling (Chart 10-1). Some patients have five or more
chronic conditions and see a range of specialists and primary
care providers per year, leading to potentially fragmented
services, high error rates and incidence of adverse events
(ADHA, 2009a). This provides an opportunity for nurses to
assume a more active role in addressing many of the issues
experienced, coordinating care, and serving as an advocate
for patients who need additional assistance to manage their
illnesses while maintaining a quality of life that is acceptable
to them. An example can be seen in the research presented
in Chart 10-2. Once a chronic condition has been diagnosed,
the focus shifts from illness prevention to managing symptoms
and promoting wellness by avoiding complications (Boogaerts
& Merritt, 2008).
Assessment: Identifying the trajectory
phase
The first step is assessment of the person to determine the
specific phase (see Table 10-2). Assessment enables the nurse
to identify the specific medical, social and psychological
problems likely to be encountered in a phase. For instance,
the problems of a person having an acute myocardial infarction
are very different from those likely to be encountered with the
same person, 10 years later, dying at home of heart failure. The
types of direct care, referrals, teaching and emotional support
needed in each situation are different as well.
Once the phase of illness has been identified, the nurse helps
prioritise problems and establish the goals of care. Identification
of goals must be a collaborative effort, with the patient, family
and nurse working together with the multidisciplinary health
care team, and the goals must be consistent with the abilities,
desires, motivations and resources of those involved.
An example of goal setting is as follows. An older man with
severe progressive COPD reports increasing difficulty breath
ing, even with the oxygen level set at 2 L/min. This interferes
with his ability to carry out activities of daily living and has
decreased his quality of life. He asks the nurse for help. The
nursing diagnosis for this problem might be ‘Activity intoler
ance related to less than adequate intake of oxygen secondary
to lung illness’, and the mutually agreed upon goal of care
might be to increase the person’s ability to care for himself.
Once goals have been established, the next step consists
of establishing a realistic and mutually agreed upon plan for
achieving them and identifying specific criteria that can be
used to assess the person’s progress. Consider a 55-year-old
woman with a dense hemiplegia following a stroke who is
hospitalised with a severe bladder infection. She reports she
has problems with incontinence and personal hygiene because
of her disability, and that she has difficulty obtaining and con
suming adequate fluids during the day because she believes this
contributes to her incontinence. The nursing diagnosis for this
problem might be ‘Toileting self-care deficit (in bladder care)
related to decreased functional ability secondary to a stroke’,
and the mutual expected outcomes of care might be to develop
strategies to facilitate bladder retraining and self-care process
and increase daily fluid intake. For many people with chronic
illness, having someone to help them with intimate bodily
activities is a threat to their independence and self-esteem,
and perhaps the first step to a nursing home or rehabilitation
centre. Therefore, they might resist someone coming into their
home to help them.
Even more challenging for many people with chronic illness
is the need to hire and oversee carers who come into their
Nurs ing Research Prof ile :
Evidence -based practice
Self-medication for chronic illness in
CALD groups
Summary
A pilot study (Williams et al., 2012) using a randomised
control trial (RCT) method compared a multifactorial
intervention designed to improve medication self-efficacy
and adherence. Seventy-eight participants (29 completed
the study), who spoke Greek, Italian or Vietnamese,
were recruited from nephrology outpatients’ clinics of
two Australian metropolitan hospitals. The translated,
multifactorial intervention consisted of a medication review,
a short PowerPoint presentation and a motivational interview,
with 12 months’ follow-up, post-baseline.
Nursing implications
Although there were no significant differences in medication
self-efficacy or adherence between the intervention and
control groups at 3, 6 and 12 months post-baseline, other
factors were highlighted that are of interest to nurses.
The pilot study demonstrated that the intervention was
not feasible due to high attrition rates. However, this work
emphasised the difficulties experienced by people with
chronic illness, where taking medicines is a long-term
feature of their management regimen. Also it showed the
complexities of conducting health education and research
into CALD groups, where English is not the primary language
and where using interpreting services is part of the interface
with health professionals.
CHART
10-2
