Textbook of Medical-Surgical Nursing 3e

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Unit 3   Applying concepts from the nursing process

ASSESSMENT Characteristics of patients with chronic illness

CHART 10-1

• 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 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. • Dying with dignity and comfort. Phases of 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

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)

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