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Unit 3
Applying concepts from the nursing process
homes to assist with
activities of daily living (ADLs),
self-care
activities, including bathing, grooming, dressing, eating, toilet
ing, and bowel and bladder care,
and
instrumental activities
of daily living (IADLs
), the complex aspects of independence
including meal preparation, grocery shopping, household man
agement, finances and transportation. It is difficult for many
people to be in a position of hiring, supervising and some
times firing people who may be providing them with intimate
physical care. The need to balance the role of recipient of
care and oversight of the person providing care may lead to
a blurring of role boundaries. However, this aspect of assisted
care may be overcome by using agencies to supply services. In
Australia, a National Disability Scheme is being trialled and it
is anticipated that this will facilitate assistive support services.
Nursing interventions
Providing direct care
Nursing care of people with chronic conditions is varied and
occurs in an assortment of settings. It can include provision of
direct care or supportive care. Direct care is often provided in
the clinic or doctor’s office, the hospital, or the person’s home,
depending on the status of the illness. Examples of direct care
may include assessing the person’s physical status, providing
wound care, managing and overseeing medication regimens
and performing other technical tasks. The availability of this
type of nursing care is one of the main reasons people can
remain at home and return to a somewhat normal life after an
acute episode of illness.
Nurses have also used ‘telehealth’ care (use of the telephone
in healthcare) to monitor patients with chronic illnesses,
deliver selected nursing interventions (e.g. counselling), and
provide ongoing education and support (Coyle, Duffy &
Martin, 2007). Nurses often provide supportive care unless
the person is hospitalised because much of the day-to-day
responsibility for managing chronic conditions rests with
the person and family. Supportive care may include ongoing
monitoring, medication administration, elimination manage
ment and teaching, counselling and serving as an advocate
for the person, making referrals and case managing. Providing
supportive care is just as important as the performance of
technical care. For example, through ongoing monitoring
that might take place either in the home or a nursing clinic
(such as a heart failure clinic), a nurse might detect impending
complications, such as signs of heart failure. The nurse might
detect these signs before they are noticeable to the person and
could make a referral (call the doctor or consult the medical
protocol in a clinic) for medical evaluation, thereby prevent
ing a lengthy and costly hospitalisation.
Providing supportive care and case management
Working with people with chronic illness or disability requires
not just dealing with the medical aspects of their disorder, but
also working with the whole biopsychosocial person—physi
cally, emotionally and socially. This holistic approach to care
requires nurses to draw on their knowledge and skills, includ
ing knowledge from the social sciences and psychology in
particular, and their skills in variable means of communication
(see Fig 10-5).
In the case of the man with COPD, for example, the lack
of sufficient resources could prevent him from hiring a home
health aide. For this reason, the nurse might want to explore
carefully the issue of resources with the man and, if there are
financial constraints, enlist the services of a social worker, with
the man’s consent, to explore possible community resources.
Since the man is having trouble breathing, the nurse should
determine whether the man is also having difficulty cooking
and eating, and whether he is losing weight because of insuffi
cient kilojoule intake to meet his nutritional needs. If cooking
is a problem, then the nurse might look into community
resources such as Meals on Wheels. If the man is losing weight,
then the nurse should advise him to eat frequent, small meals
to lessen the fatigue associated with eating and to supplement
meals with high-protein drinks.
In the case of the woman with stroke, the nurse might want
to explore the extent of the woman’s physical limitations, when
during the day she has the most difficulty with incontinence,
and whether this might be related to fatigue. If fatigue is a
factor, the nurse might explore the possibility of having a home
health aide to help her with some of her self-care activities.
This would enable the woman to conserve her energy for social
activities and personal care. The nurse would also discuss with
the woman the reasons for an adequate intake of fluids. If the
woman is too busy or tired to make frequent trips to the sink
or refrigerator to get fluids, the nurse might help the woman
develop strategies for saving time and energy. For example, the
woman could attach a bottle of water to her walking frame and
carry it around with her, or strategically place bottles of water
or other liquids around the house to increase their accessibility.
The nurse might also explore with the woman the types of
caffeine-free fluids that she enjoys drinking.
Nurses and other healthcare professionals need to recognise
the person’s ideas about the quality of their life, even though
it may be difficult to see patients make unwise choices and
decisions about lifestyles and illness management. People
have the right to receive care without fearing ridicule or
refusal of treatment, even if their behaviours (e.g. smoking,
substance abuse, overeating and failure to follow healthcare
Figure 10-5
Alternative communication methods and types
of patient education are essential to the provision of appropriate
health-related information to people with disabilities.
(© Will & Deni McIntyre/Photo Researchers, Inc.)
